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AN    EPITOME    OF    MENTAL 
DISORDERS 


AN   EPITOME   OF 

MENTAL    DISORDERS 

A  Practical  Guide  to  ^Etiology, 
Diagnosis,  and  Treatment 


FOR  PRACTITIONERS,  ASYLUM,  AND  R.A.M.C. 
MEDICAL     OFFICERS 


By 
E.  FRYER  BALLARD,  M.B.,  B.S.  (Lond.) 

CAPT.    R.A.M.C.    (T.),    MEDICAL    OFFICER   IN    CHARGE   OF   THE   OBSERVATION    AND    MENTAL 

BLOCK,    2ND    EASTERN    GENERAL   HOSPITAL    (T.F.),  BRIGHTON  J       SOMETIME  ASSISTANT 

MEDICAL     OFFICER     SOMERSET    COUNTY     ASYLUM,     WELLS  ;  MEMBER    OF     THE 

MEDICO-PSYCHOLOGICAL   ASSOCIATION    OF    GREAT    BRITAIN    AND    IRELAND 


PHILADELPHIA 
P.    BLAKISTON'S    SON    &    CO. 

1012  WALNUT  STREET 
1917 


Printed  in  Great  Britain 


X  C  C5\ 
J>%\ 


PREFACE 

This  little  book  is  not  intended  for  students  of  medicine, 
but  for  practitioners  and  assistant  medical  officers  in 
asylums.  The  writer  has  not  aspired  to  write  a  textbook 
of  psychiatry,  but  a  concise  practical  aid  to  the  diagnosis 
and  treatment  of  the  more  common  varieties  of  mental 
disorder  as  met  with  in  general  practice  and  lunatic 
asylums. 

The  works  of  standard  authors  have  of  course  been 
freely  consulted.  A  certain  number  of  alienists  deny  the 
existence  as  clinical  entities  of  nearly  all  forms  of  insanity, 
and  are  content  to  await  with  patience  the  time  when 
pathology  shall  elucidate  the  problems  of  aetiology  and 
classification  for  good  and  all. 

Although  we  are  at  present,  in  most  cases,  only  justified 
in  the  use  of  the  term  syndrome  as  applied  to  mental 
disorders,  that  attitude  the  present  writer  ventures  to 
think  is  the  negation  of  all  clinical  progress,  and  moreover 
tends  directly  to  discourage  the  study  of  insanity  by 
practitioners  who  have  only  facilities  for  clinical  investiga- 
tion. 

It  is  hoped  that  an  inevitable  dogmatism  of  style  in 

Part  I  will  be  pardoned.     In  a  summary  of  this  nature 

one  cannot  be  continually  prefixing  "  in  the  majority 

of  cases  "  "in  its  typical  form  "  etc.     It  is  the  typical 

'form  that  is  described. 

It  is  also  hoped  that  the  division  into  chapters  devoted 

vii 


Mr 

d 


viii  PREFACE 

to  states  of  Excitement,  Depression,  Stupor,  etc.,  will 
facilitate  the  diagnosis,  etc.,  of  individual  cases.  It  is 
an  easy  matter  as  a  rule  to  decide  at  once  the  general 
clinical  colouring  of  a  case,  whether  the  most  prominent 
features  produce  a  picture  of  stupor  or  of  excitement, 
for  example,  and  the  chapter  devoted  to  the  appropriate 
classes  can  be  consulted.  Of  course  these  divisions  are 
entirely  arbitrary  and  betoken  no  relationship  between 
the  very  diverse  syndromes  thus  grouped  into  chapters 
to  render  reference  easy. 

The  classification,  adapted  from  Tanzi,  is  set  out  on 
the  following  page,  and  like  all  classifications  of  mental 
disorders  based  upon  aetiology,  is  provisional,  and  in 
some  cases  more  or  less  hypothetical. 

In  enumerating  symptoms  a  constant  order  and  psycho- 
logical systematization  have  been  avoided  :  and  it  is 
especially  wished  to  impress  upon  the  reader  that  it  is  not 
the  incidence  of  individual  symptoms  that  forms  the 
basis  of  the  clinical  distinction  of  the  varieties  of  insanity, 
but  the  presence  of  some  symptoms  together  with  others, 
interdependent,  or  interacting  and  due  perhaps  to  a 
related  pathological  process. 

Part  II  is  more  theoretical  and  discursive.  In  it  the 
less  well  defined  mental  disorders  are  briefly  discussed. 
A  Glossary  of  psychological  terms  used  will  be  found  at 
the  end  of  the  book. 

Brighton. 
1917. 


CLASSIFICATION  OF  MENTAL  DISORDERS 

DISORDERS    IN    WHICH    THE    HEREDITARY    FACTOR 
IS    ESSENTIAL    OR    IMPORTANT 

Imbecility 

Paranoia 

Dementia  praeeox 

Persecutory  hypochondria 

Manic-depressive  insanity 

Psychasthenia 

Hysteria 

Epileptic  insanity 


DISORDERS    IN    WHICH  THE    HEREDITARY 
FACTOR  IS  NEGLIGIBLE 


(Prom 

Acute  , 

.,  exhaustion, 

endogenous  -j  ,  .         ' 

.       .  psychical 

poisonings     \ J 
c  \  stress,  etc. 

Ursemic  delirium 


Amentia 


'Agitata. 
Attonita. 
Para- 
noides. 


Acute 
exogenous 
poisonings 

Subacute 

and  chronic  | 

endogenous  | 

poisonings 
Subacute       \ 

and  chronic  [  Alcoholic 

endogenous  [    syndromes 
,   poisonings  I 


From  bacterial  toxins,  e.  g.  fevers, 
pyogenic    infections,    chorea, 
secondary  syphilis,  etc. 

From  drugs,  e.g.  morphia,  cocaine, 
alcohol  (delirium) 


Acute 
Con- 
fusional 
Insanity 


Thyroid  psychoses 


Hallucinatory  delusions 
Korsakoff's  syndrome 
Alcoholic  "  paranoia  " 
Pseudo-paresis 


IX 


CLASSIFICATION   OF   MENTAL   DISORDERS 


Cerebropathies 


Organic 


f  Congenital Idiocy 

I  Cerebral 
tumours, 
trauma, 
haemor- 
rhage, etc. 

(Arterio-pathie  J  Senile  dementia  (in  part) 
J  (Arteriosclerotic  dementia 


Acquired  in 
later  life 


^  Insanity 

with  gross 
r  brain 

lesion 


Degenerations  ^Syphilitic  General  paralysis 


PART  I 

COMMON  TYPES   OF  INSANITY 
CHRONOLOGICAL  TABLE  OF  CONTENTS 


CHAPTER    I 
STATES  OF  EXCITEMENT 

Mania  ..... 

Excitement  in  Dementia  Precox 
Acute  Coneusional  Insanity 
Excitement  in  G.P.I.  . 
Delirium  Tremens 
Alcoholic  Pseudo-paresis    . 
Excitement  in  Epilepsy 
Excitement  ln  Gross  Cerebral  Disease 
Excitement  ln  Senile  Dementia 
Excitement  due  to  Drugs  . 


PAGE 

13 
18 

22 
28 
33 
36 

38 
42 
46 

47 


CHAPTER    II 
STATES  OF  DEPRESSION 


Melancholia         .... 
Depression  in  Dementia  Precox 
Depression  ln  G.P.I.    . 
Depression  of  Involution  . 
Depression  in  Epilepsy 

xi 


64 
56 
58 
59 


xu 


CONTENTS 


CHAPTER    III 
DELUSIONAL  STATES 


Paranoia.      ..... 

Pebsecutoby  HyPOCHONDBIA 
Dementia  Paranoides. 
Seattle  Delusions 
Acute  Hallucinatory  Delusions 
Chronic  Hallucinatory  Delusions 
Alcoholic  "  Paranoia  " 
Delusions  ln  G.P.I. 
Paranoidal  Amentia   . 
Polyneuritic  Psychosis  (Korsakoff) 


PAGE 

61 
63 
66 
68 
69 
71 
74 
76 
81 
83 


CHAPTER    IV 

STATES  OF  STUPOR 

Circular  Stupor           .......  86 

Katatonic  Stupor        .......  87 

Amentia  Attonlta        .......  89 

Simple  Stupor  ln  Dementia  Precox  ....  90 

Stupor  ln  Epilepsy      .......  91 

Stupor  ln  G.P.I. 93 

"  Maniacal  Stupor  "    .  .  .  .  .  •  .95 


CHAPTER    V 
STATES  OF  MENTAL  ENFEEBLEMENT 


Dementia  Paralytica 
Dementia  Prjscox 
Senile  Dementia 
arterio- sclerotic  dementia 
Syphilitic  Dementia    . 
Epileptic  Dementia 
Alcoholic  Dementia    . 
Apoplectic  Dementia  . 
Imbecility   .... 


98 
101 
102 
104 
105 
107 
112 
114 
114 


CONTENTS 


xm 


PART   I  (continued.) 
ALPHABETICAL  LIST  OF  FORMS  OF   INSANITY 

PAGE 

ACUTE  CONFUSIONAL  INSANITY. 

1.  Amentia  Agitata       .          .                    .          .  .23 

2.  Amentia  Attonita     .          .          .          .          .  .89 

3.  Amentia  Paranoides  (Delusional  Form)  .  .        81 

4.  From    Exogenous    Toxins,    i.e.    Bacterial  or 

Drug 22  &  47 

5.  Uremic     ........       22 


ALCOHOLIC   INSANITY. 

1.  Acute    Hallucinatory    Delusions    (Alcoholic 

Mania)  .... 

2.  Alcoholic  Dementia. 

3.  Alcoholic  "Paranoia"     . 

4.  Alcoholic  Pseudo-paresis 

5.  Chronic  Hallucinatory  Delusions 

6.  Delirium  Tremens     . 

7.  Polyneuritic  Psychosis  (Korsakoff) 


69 
112 
74 
36 
71 
33 
83 


ANOMALIES. 

1.  Imbecllity 

2.  Paranoia  (?) 


114 
61 


DEMENTIA  PRECOX. 


1.  Dementia  in 

.101 

2.  Dementia  Paranoides 

66 

3.  Depression  in  . 

54 

4.  Excitement  in  . 

18 

5.  Katatonic  Stupor     . 

87 

6.  Simple  Stupor  in 

,          ,    '       •        9Q 

XIV 


CONTENTS 


EPILEPTIC   INSANITY. 

1.  Dementia,  in 

2.  Depression  in  . 

3.  Excitement  in  . 

4.  Stupob  in. 


page 

107 
59 
38 
91 


GENERAL   PARALYSIS. 


1.  Delusions  in     . 

.       76 

2.  Dementia  in 

98 

3.  Depression  in  . 

56 

4.  Excitement  in  . 

28 

5.  Stupor  in           ... 

93 

GROSS   CEREBRAL   DISEASE. 

1.  Apoplectic  Dementia 

2.  Arteriosclerotic  Dementia 

3.  Excitement  in  Cerebropathies 

4.  Syphilitic  Dementia. 


114 

104 

42 

105 


MANIC-DEPRESSIVE   INSANITY. 

1.  Circular  Stupor 

2.  Mania        .... 

3.  "  Maniacal  Stupor  " 

4.  Melancholia 


86 
13 
95 
49 


PERSECUTORY  HYPOCHONDRIA. 


63 


SENILE   INSANITY. 

1.  Dementia  Senilis 

2.  Delusional  Forms 

3.  Depressed  Forms 

4.  Excited  Forms 


102 
68 
58 
46 


CONTENTS 


xv 


PART   II 

CHRONOLOGICAL  TABLE   OF  CONTENTS 


CHAPTER    VI 


BORDERLINE   PSYCHOSES. 


PAGE 


1 .  HyPOMANIA,  AND  THE  MANIC  DEPRESSIVE  DIATHESIS       119 

2.  Eccentrics,  Cranks,  etc.  .  .  .  .  .123 


3.  psychasthenia  ...... 

4.  Masked  Epilepsy,  and  Automatism  .      ,    . 

5.  Thyroid  Psychoses  and  their  Relationships 

6.  Hysteria  ....... 

7.  Constitutional  Immorality 


124 
128 
132 
135 
147 


CHAPTER    VII 
SHELL-SHOCK,  including  Battle  Strain,  etc. 


151 


CHAPTER    VIII 

COMBINED   and   ATYPICAL   PSYCHOSES  -  .166 

1.  Combinations    of    Anomalies    with    Psychoses 


and  Neuroses   ..... 

2.  Combination  op  Anomalies  with  Anomalies 

3.  Combinations    of    Psychoses    and     Neuroses 

with  each  other  .... 

4.  Complicated  Combined  Psychoses  . 


GLOSSARY 201 


166 
176 

178 
198 


SOME    NOTES    ON   THE    GENERAL    CAUSATION 
AND  TREATMENT  OF  MENTAL  DISORDERS 

In  the  preceding  table  of  classification  and  under  the 
headings  of  the  Syndromes  discussed  in  the  following 
pages,  some  simple  suggestions,  at  present  usually  regarded 
as  correct,  as  to  the  setiology  of  mental  disorders,  are 
implied  or  enumerated. 

But  just  as  it  is  the  exception  for  one  parti- 
cular symptom  to  be  pathognomonic  of  one  form 
of  insanity,  so  it  is  impossible  for  one  causative 
factor  alone  to  be  at  the  root  of  a  psychosis.  This  is 
true  even  of  the  few  varieties  of  more  or  less  known 
origin  ;  for  example,  every  chronic  alcoholic  does  not 
become  insane,  every  old  person  does  not  become  a 
dement,  every  syphilitic  does  not  develop  General  Par- 
esis. Two  factors  are  responsible  for  the  development 
of  mental  disorder,  the  individual  and  the  conditions 
to  which  he  is  subjected.  The  relative  importance  of 
each  factor  varies  in  the  individuals  and  the  types  of  mental 
disorder.  The  individual  is  the  product  of  his  pedigree, 
his  personal  ego,  and  his  past  reactions  to  his  environ- 
ment. 

It  is  beyond  the  scope  of  this  book  to  discuss  the  theories 
of  setiology  at  any  length,  fascinating  as  they  are.  It  is 
only  desired  to  indicate  here  the  complicated  nature  of 
the  subject,   and  to  forewarn  the  student  of  insanity 

e.m.d.  l  1 


2      AN  EPITOME   OF  MENTAL  DISORDERS 

against  the  pitfall  of  erroneous  prognostication,  and  the 
fatalistic  view  of  the  inevitability  of  mental  breakdown, 
or  its  permanency,  in  persons  who  from  their  heredity, 
physical  metabolism,  or  environment,  are  more  liable 
than  others  to  develop  some  form  of  mental  disorder. 

Fortunately  a  man  is  an  individual ;  he  possesses  a 
distinct  ego  peculiar  to  himself,  and  this  may  be  potent 
enough  to  counteract  all  the  recently  inherited  tendencies, 
as  well  as  the  buffets  of  disease  and  circumstance. 

We  frequently  see  a  stock  labelled  as  psychically 
degenerate  (whatever  that  may  mean)  because  a  few 
members  of  the  family  in  preceding  generations  have 
been  insane.  This  is  a  misnomer — a  confounding  of 
inherited  instability  with  degeneracy.  The  vast  majority 
of  the  members  of  these  unstable  stocks  never  break 
down  at  all,  and  those  that  do,  almost  invariably  succumb 
as  the  result  of  some  superadded  incidental  and  external 
cause. 

On  the  other  hand,  quite  commonly  a  typically  so- 
called  degenerative  disease,  such  as  dementia  prsecox, 
will  crop  up  as  it  were  as  a  "  sport,"  in  apparently  per- 
fectly sound  stocks. 

Insane  heredity  is  very  rarely  direct  and  similar.  In 
fact,  all  that  can  be  strictly  said  to  be  inherited  is  a  more 
or  less  strong  tendency  to  general  nervous  or  mental 
breakdown.  The  more  hereditary  types  are  indicated 
in  the  classification. 

By  appropriate  education,  suitable  mode  of  life  and 
environment,  and  in  virtue  of  the  individual's  ego,  an 
inherited  tendency  may  frequently  be  defeated  ;  and 
by  the  reverse  state  of  affairs,  repeated  in  succeeding 
generations,  a  sound  stock  may  probably  be  rendered 
"  degenerate  "  so  far  as  all  practical  tests  are  concerned. 

Some  few  stocks,  contrary  to  the  usual  law  of  nature, 
exhibit  a  greater  tendency  towards  insanity  than  towards 


NOTES  ON  CAUSATION  AND   TREATMENT      3 

normality.  Nearly  all  the  members  are  wholly  or  parti- 
ally insane.  (Here  again,  however,  the  tendency  is 
merely  excessive  as  compared  with  unstable  stocks. 
There  is  no  hard  and  fast  line  between  them.)  These  are 
regarded  as  the  truly  "  degenerate  "  stocks,  and  they 
are  very  rare.  Therefore,  in  the  vast  majority  of  cases 
of  insane  heredity  all  that  is  inherited  is  a  psychical 
instability  which  renders  its  subject  more  liable  to  break- 
down as  the  result  of  external  causes  than  are  normal 
people — an  instability  which  varies  in  individuals  and 
merges  into  the  normal  type. 

This  inherent  tendency  to  insanity  can  with  care  very 
often  be  detected  in  childhood  or  adolescence,  and  its 
development  into  mental  disease  can  in  many  cases  be 
prevented  by  suitable  measures.  If  family  doctors  only 
recognized  signs  of  mental  instability  as  such  in  their 
young  patients,  the  incidence  of  mental  disorders  would 
be  reducible  in  no  small  degree. 

Children  and  adolescents  who  take  to  vice,  exhibit 
explosions  of  uncontrollable  temper,  night- terrors,  chronic 
irritability,  vengefulness,  love  of  solitude,  valetudin- 
arianism, moroseness,  undue  obstinacy  or  perversity, 
or  egotism,  apathy,  absence  of  natural  affection,  etc., 
etc.,  are  not  merely  crying  out  for  rhubarb  and  soda,  useful 
as  these  are  as  adjuncts  ;  they  are  advertising  their 
special  liability  to  insanity.  These  mental  traits  are 
not  infrequently  accompanied  by  certain  abnormalities 
of  the  physical  structure  in  the  unstable  individual, 
known  as  stigmata  of  "  degeneration  " — an  unjustifiable 
limitation.  The  less  gross  and  more  common  stigmata 
are  of  exceedingly  common  occurrence  in  simple  neurotics, 
in  the  unstable  mental  types  now  under  consideration, 
and  in  people  of  artistic  temperament  (themselves  for 
the  most  part  of  nervous  type),  by  whom  some  of  the  best 
work  of  the  world  is  done, 


4   AN  EPITOME  OF  MENTAL  DISORDERS 

The  reader  who  is  interested  in  these  stigmata,  is 
referred  to  Dr.  Stoddart's  book  on  Mind  and  its  Dis- 
orders. 

Certain  persons  of  psychopathic  inheritance  manifest  a 
special  temperament  or  diathesis,  indicating  an  extra 
liability  to  special  neurotic  or  psychical  disorders. 

Examples  of  this  are  seen  in  the  case  of  certain  epileptics, 
hysterics,  some  maniacs  and  melancholies,  paranoiacs, 
etc.,  and  will  be  discussed  briefly  under  their  own  titles. 
It  is  not  unlikely  that  we  may  succeed  later  in  separating 
other  temperaments  or  diatheses  that  are  peculiarly 
liable  to  other  special  forms  of  psychosis.  In  any  case 
these  temperaments  probably  merely  amount  to  signs  of 
liability  to  special  attacks  of  psychosis,  etc.,  in  virtue 
of  which  their  possessors  are  more  prone  to  such  attacks, 
merely  in  a  question  of  degree,  than  are  other  individuals 
lacking  them.  Peculiarities  of  psychical  temperament 
are  probably  associated  with  inherent  metabolic  vaso- 
motor and  other  bodily  conditions,  and  the  term  temper- 
ament as  used  here  is  intended  to  include  these  physical 
diatheses  where  such  are  associated. 

It  is  impossible  to  lay  down  rules  for  the  treatment 
of  children  or  adolescents  of  unstable  mental  type ; 
each  case  must  be  treated  upon  its  own  merits. 

As  a  general  rule,  it  may  be  said  that  education  should 
be  directed  towards  the  attainment  of  physical  perfection 
rather  than  intellectual  power  and  knowledge.  The 
pursuit  of  sports  and  games  should  be  encouraged,  and 
school  competition  in  general  subjects  prohibited.  In 
most  cases  these  children  are  much  better  sent  to  a  good 
public  school,  but  preferably  a  day  one. 

A  great  number  suffer  from  adenoids  and  phimosis  ; 
these  defects  should  be  remedied  by  operation.  Solitary, 
sensitive  children  are  occasionally  unable  to  stand  the 
life  of  a  public  school,  and  the  medical  attendant  must  be 


NOTES   ON  CAUSATION  AND  TREATMENT       5 

prepared  for  the  failure  of  this  part  of  his  prescrip- 
tion. 

If  the  boy  (or  girl)  is  unhappy  or  the  signs  of  instability 
increase,  he  should  be  taken  into  the  country,  found 
some  outdoor  hobbies  and  some  friends  of  like  taste, 
and  allowed  to  run  wild,  his  education  being  carried  on 
quietly  at  a  local  school. 

It  is  better  to  have  a  comparatively  ignorant  boy  than 
a  lunatic.  Neurasthenic  and  hysterical  children  should 
be  kindly,  but  firmly,  subjected  to  a  hardening  process  of 
education.  Seclusive,  reserved  types  should  be  encour- 
aged to  air  their  troubles,  discuss  their  difficulties  and 
mix  with  their  acquaintances. 

These  suggestions  are  for  the  most  part  truisms,  but 
the  importance  of  suitable  nurture  for  children  psychic- 
ally unstable  cannot  be  over-estimated.  With  regard 
to  adolescents  of  this  type,  other  points  arise  for  con- 
sideration, the  most  important  being  the  development 
of  the  sexual  instinct. 

The  attempt  at  complete  suppression  of  this  instinct  in 
unstable  types  makes  for  mental  disorder  ;  constant  per- 
verted indulgence  has  the  same  effect  ;  sudden  cessation 
of  masturbation  may  have  a  similar  effect.  The  aim 
of  the  physician,  after  he  has  explained  matters,  and 
caused  his  patient  to  face  the  conflict  between  the  instinct 
and  other  forces,  should  be  to  render  the  instinct  as 
unconscious  as  possible,  and  to  find  legitimate  methods 
of  sublimating  it,  e.  g.  by  the  gospel  of  games,  by  finding 
objects  for  the  patient  to  love,  e.  g.  relations,  friends, 
religions,  pets  ;  and  by  treating  masturbation,  not  as  a 
crime,  but  as  a  symptom. 

In  brief,  unstable  children  at  puberty  or  before  should 
have  the  sexual  scheme  of  things  told  to  them  by  a  doctor, 
male  or  female,  according  to  their  own  sex,  and  sub- 
sequently be  given  a  short  course  of  bromides.     Young 


6   AN  EPITOME  OE  MENTAL  DISORDERS 

people  of  this  type  should  marry  early,  being  duly  warned 
of  the  necessity  of  moderation.  Indeed,  moderation  in 
all  things  should  be  their  golden  rule. 

The  possibility  of  unstable  children  of  such  a  marriage 
need  not  disturb  us.  The  majority  will  probably  make 
good  citizens.  If  the  other  parent  is  also  unstable, 
the  progeny  will  be  more  likely  to  be  the  same,  and  some 
of  them  may  become  insane.  But  the  tendency  of 
nature  is  towards  the  normal.  If  either  of  the  parent's 
stocks  is  truly  (so-called)  "  degenerate,"  some  of  the 
children  will  almost  certainly  be  so  also. 

Mott  has  shown,  however,  that  in  these  more  strongly 
hereditary  types  the  insanity  tends  to  occur  at  an  earlier 
age  in  each  succeeding  generation. 

Now  imbecility  is  regarded  as  the  final  expression  of 
the  degeneration  of  the  stock,  and  imbeciles  stand  a 
good  chance  in  these  days  of  being  prevented  from  pro- 
pagating their  race — moreover,  precocious  dements, 
examples  of  the  other  often  so-called  typical  degenerative 
condition,  are  subject  in  many  cases  to  the  same  restric- 
tions, viz.  they  are  confined  before  they  breed. 

In  this  way,  therefore,  nature,  true  to  her  rule,  gets 
back  to  the  normal  in  the  stock  by  eradicating  the  hopeless 
element. 

Selfishness  and  egotism  are  predisposing  causes  of 
insanity.  Altruism  tends  to  keep  a  man  sane.  An 
altruist  may  get  an  incidental  attack  of  mental  disorder 
as  the  result  of  stress,  but  he  almost  invariably  recovers  ; 
an  egotist  is  a  potential  chronic  lunatic.  But  it  must  be 
remembered  that  a  man  of  exemplary  conduct  may  be  a 
great  egotist. 

This  being  the  case,  the  physician  and  friends  of 
unstable  children  and  adolescents,  should  do  their  utmost 
to  encourage  an  altruistic  view  of  life,  and  an  appropriate 
code  of  conduct  in  these  potential  psychopaths  ;    so  far 


NOTES  ON  CAUSATION  AND  TREATMENT       7 

as  their  temperaments  will  permit,  for  there  can  be  no 
manner  of  doubt  that  self-suppression,  i.  e.  the  suppression 
of  the  sum  of  powerful  emotional  tendencies  and  instincts 
of  the  individual,  tends  towards  insanity  in  persons  of 
neuropathic  inheritance  or  type. 

Speaking  from  a  purely  scientific  point  of  view,  the 
Christian  religion  admirably  serves  the  former  purpose, 
without  necessitating  the  latter  undesirable  result, 
providing,  as  it  does,  for  the  legitimate  dissipation  of 
emotional  complexes,  both  in  feeling  and  mode  of  life, 
e.  g.,  love  of  God,  of  one's  fellow  men,  philanthropy, 
etc.  But  the  religion  must  not  be  a  narrow  egotistical 
one. 

It  is  a  common  idea  amongst  the  laity  that  religion 
sends  people  mad  (this  erroneous  view  is  not  unknown 
among  medical  men).  The  truth  is  that  persons  incu- 
bating insanity  not  infrequently  suddenly  begin  to  talk 
and  think  a  good  deal  about  religion  (the  occult  force 
with  which  they  are  most  familiar),  and  seize  upon  it  as 
an  explanation  of  abnormal  thoughts  and  feelings  inex- 
plicable to  them  upon  any  ordinary  grounds. 

Similarly,  debauchery  seldom  results  in  insanity ; 
but  incipient  lunatics  losing  their  control  often  take 
excessively  to  it.  Neurasthenia  does  not  predispose 
to  mental  disease,  but  many  psychoses  exhibit  its  symp- 
toms in  their  early  stages.  An  exception  to  this  rule 
is  the  liability  of  acute  neurasthenics  to  confusional 
attacks,  the  term  neurasthenia  being  used  here  to 
include  the  asthenic  and  the  anxiety  varieties. 

Marriage,  as  suggested  above,  predisposes  towards 
sanity,  and  yet  occasionally  a  mental  breakdown  follows 
closely  upon  it.  These  marriage  psychoses  generally 
occur  in  persons  who  marry  relatively  late  in  life. 

Intellectual  labour,  however  arduous,  never  sends 
anybody  insane,  provided  that  it  is  congenial.     Uncon- 


8      AN  EPITOME  OF  MENTAL  DISORDERS 

genial  work  involving  a  persistently  unpleasant  emotional 
tone,  not  uncommonly  results  in  psychoses  or  neuroses. 

Emotional  disturbances  of  unpleasant  nature  generally, 
are  potent  causes  of  mental  disorder  in  certain  types  ; 
those  most  liable  to  be  thus  affected  are  persons  of  quiet, 
self-contained,  self-controlled  habit.  Vivacious,  impuls- 
ive, excitable  and  even  hysterical  people,  seldom  become 
insane.  When  they  do,  the  form  of  insanity  is  not  as  a 
rule  of  a  grave  variety. 

All  the  common  conditions  mentioned  above  as  causes 
of  mental  disorder  are  mere  co-operating  factors  in  its 
production. 

Incidentally,  they  are  just  as  likely  to  result  in  the  case 
of  certain  individuals  in  a  neurosis. 

To  sum  up,  some  of  the  following  conditions  by  their 
interaction  are  the  common  causes  of  mental  affections  : 

1.  True  so-called  psychical  degeneracy  (often  not 
requiring  any  conspicuous  contributory  causes). 

2.  Inherited  or  acquired  instability. 

3.  Faulty  up-bringing  or  environment. 

4.  Suppression  of  emotional  complexes. 

5.  Changes  in  sexual  metabolism,  e.  g.,  adolescence, 
climacteric. 

6.  Unpleasant  emotional  states,  whether  sudden,  such 
as  fright ;    or  prolonged,  such  as  worry  and  unhappiness. 

7.  Physical  affections,  e.  g.,  exhausting  illnesses. 

8.  Poisons,  e.  g.,  alcohol. 

9.  Organic  cerebral  disease. 

10.  Egotism  (often  found  in  persons  of  unstable 
stock). 

Hints  for  the  treatment  of  the  individual  psychoses 
will  be  mentioned  under  their  titles.  They  are  mainly 
practical  suggestions  along  medical  lines. 

These  present  brief  notes  ought  perhaps  to  contain 
some  reference  to  psychical  treatment. 


NOTES  ON  CAUSATION  AND  TREATMENT       9 

From  personal  experience  of  its  application  the  present 
writer  is  not  qualified  to  speak  upon  the  subject  of  psycho- 
analysis— a  process  by  which  some  forgotten  or  sup- 
pressed conflict  is  revived  in  the  patient's  mind  with  the 
idea  of  showing  him  how  to  tackle  it  upon  scientific 
grounds,  and  so  free  him  from  some  pathological  symp- 
toms which  are  supposed  to  be  due  to  its  unnatural 
suppression.  The  method  is  said  to  have  done  good 
in  some  cases,  for  the  most  part,  I  believe,  border-line 
types,  hysterics  or  psychasthenics,  but  owing  to  the  length 
of  time  required  for  it  it  is  beyond  the  scope  of  the 
majority  of  practitioners,  whatever  their  views  as  to  its 
value. 

Psycho-analysis  is  of  course  always  open  to  criticism 
that  any  success  it  has  is  due  to  the  continual  suggestion 
of  recovery  it  supplies.  And,  perhaps  not  infrequently 
the  suggestion  without  the  analysis  is  equally  efficacious. 
Even  so,  the  main  point  is  the  recovery  of  the  patient, 
and  that  appears  to  have  followed  the  employment  of 
psycho-analysis  in  some  cases.  (See  also  page  194, 
and   Hysteria,    p.  141) 

I  am  afraid  that  there  is  some  justification  for  the 
view  that  psycho-analysis  is  a  form  of  mental  vivisection, 
instructive  to  the  operator  but  painful  and  at  times 
unnecessary  or  harmful  to  the  patient.  I  think  there 
can  be  no  doubt,  in  spite  of  isolated  unwarranted  assump- 
tions on  the  part  of  its  advocates,  that  it  has  furnished 
valuable  information  concerning  psychical  processes. 
But  it  seems  to  me,  that  though  showing  the  patient 
his  conflicts,  psycho-analysis  fails  to  supply  him  with 
the  proper  means  of  sublimation.  To  say  that  honest 
and  sincere  psycho-analysis  is  immoral  is  not  only  un- 
true but  silly.  A  psycho-analysed  person  is  enabled  to 
realize  what  we  have  all  been  taught  for  two  thousand 
years,  that  we  are  naturally   selfish    and    more  or  less 


10    AN  EPITOME   OF  MENTAL  DISORDERS 

wicked,  that  our  instincts  and  personal  tendencies  if 
allowed  free  play  are  not  in  accordance  with  a  mode  of 
conduct  productive  of  the  best  racial  results,  but  there 
psycho-analysis  though  curing  a  neurosis  for  the  time — 
stops. 

There  can  be  no  manner  of  doubt  that  the  personal 
influence  and  suggestion,  conscious  or  unconscious,  of 
the  physician  exercises  a  very  great  power  for  good  over 
the  patient.  If  not  directly  curative,  which  unfortunately 
it  seldom  is,  it  at  least  promotes  his  comfort  and  well- 
being,  retards  and  at  times  checks  the  progress  of  the 
disease,  and  is  invaluable  in  the  management  of  him. 

It  is  profoundly  true  that  border-line,  neurotic  types,  and 
incipient  cases  of  insanity,  with  whom  it  is  difficult  to  get 
en  rapport  (not  by  means  of  hypnotism),  those  that  are 
not  suggestible,  those  in  whom  one  encounters  an  undue 
reticence,  perversity  or  mental  resistance,  are  the  types 
most  likely  to  develop  definite  insanity,  and  least  likely 
to  recover  therefrom. 

Therapeutic  suggestive  conversation  with  these  early 
or  border-line  types  of  disorder  is  never  wasted,  nor  for 
that  matter,  with  any  lucid  mental  patient.  The  methods 
to  be  pursued  cannot  be  laid  down  ;  they  are  a  question 
of  sympathy,  personality,  and  the  type  of  patient. 

Some  old  general  practitioners,  if  they  had  the  requisite 
knowledge  of  the  workings  of  the  sane  and  insane  mind, 
would  perhaps  emulate  some  of  the  foremost  psychiatrists 
of  the  day  on  this  head.  Unfortunately,  prolonged  resi- 
dence in  asylums  rather  tends  to  blunt  the  wider  faculties 
of  physicians,  yet  such  a  means  of  study  is  practically 
the  only  one  available  in  this  country. 


PART  I 
COMMON    TYPES    OF    INSANITY 


CHAPTER  I 

STATES  OF  EXCITEMENT 

1.     MANIA 

Mania  is  now  generally  regarded  as  a  phase  of  manic- 
depressive  insanity,  which  is  thought  to  be  based  upon 
a  constitutional  metabolic  or  temperamental  condition, 
often  hereditary,  rendering  its  subjects  more  liable  than 
are  normal  people  to  attacks  of  excitement  or  depression 
from  slight  or  no  very  obvious  external  causes. 

A  few  cases  of  mania  manifest  no  phase  of  depression 
at  any  time,  the  majority  exhibit  a  short  stage  preceding 
or  terminating  the  attack  of  excitement,  others  alternate 
from  one  ti>  the  other  with  or  without  a  period  of  equi- 
librium between. 

Some  persons  develop  a  single  isolated  attack  of  this 
form  of  insanity,  from  which  they  recover,  the  majority 
have  recurrences,  others,  after  one  or  more  attacks 
become  permanently  insane — according  to  the  ab- 
sence or  presence  and  strength  of  the  constitutional 
tendency  and  the  nature  of  the  mode  of  life  and  environ- 
ment. Usually  the  single  isolated  attack  of  a  lifetime 
indicates  no  particular  manic  depressive  temperament 
(i.  e.,  tendency)  in  the  patient,  and  none  such  is  to  be 
observed  in  his  normal  condition. 

These  single  attacks  usually  follow  definite  external 
causes. 

13 


14  COMMON  TYPES   OF  INSANITY 

Symptoms 

The  chief  features  of  acute  mania  are  as  follows  (for 
Glossary  vide  p.  202)  : — • 

1.  Genuine  intellectual  and  emotional  excitement  with 
proportionate  motor  unrest,  "  press  of  occupation,"  i.  e., 
the  patient  must  always  be  doing  and  talking. 

2.  Incoherent  speech  due  to  rapid  flow  and  change 
of  ideas.  This  talking  is  disconnected,  but  not  meaning- 
less. 

3.  Keen  perception,  and  hypersensitiveness  to  external 
impressions,  with  good  comprehension  and  memory,  and 
clearness  about  immediate  surroundings. 

4.  Divertibility,  i.  e.,  the  patient's  line  of  thought, 
conduct,  and  emotional  tone  can  be  altered  by  sugges- 
tion or  by  any  chance  percept.  Passive  attention  is 
exaggerated,  but  voluntary  not  sustained. 

5.  Rapid  changes  in  the  emotional  state,  which  is, 
however,  always  sincere.  The  prevailing  tone  is  one  of 
exaltation  and  boisterous  cheerfulness. 

6.  Absence  of  hallucinations.  Illusions  may  occur, 
both  visual  and  auditory,  resulting  from  faulty  associa- 
tion of  ideas  due  to  their  rapid  flight.  So,  also,  may 
transitory  delusions  in  accordance  with  the  mood  (for 
periodic  types  of  mania,  p.  15). 

7.  Gradual  onset  as  hypomania,  a  milder  type  of 
exaltation  not  unlike  the  early  stages  of  physiological 
alcoholic  intoxication. 


Prognosis 

The  outlook  for  an  individual  attack  is  good  :  the 
majority  of  cases  completely  recover  :  but  recurrence  is 
almost  the  rule.  After  numerous  attacks  the  patient 
becomes   impaired   in   judgment   and   self-control ;     he 


MANIA  15 

loses  his  autocriticism,  and  exhibits  some  degree  of  weak- 
mindedness. 

Some  attacks  of  excitement  never  completely  subside, 
but  persist  in  an  attenuated  form,  with  more  or  less 
periodical  exacerbations  ;  thus  presenting  the  picture  of 
chronic  mania.  These  chronic  cases  are  prone  to  develop 
varying  transitory  and  incoherent  delusions. 

In  certain  predisposed  persons  attacks  of  mania  are 
periodical,  and  occur  more  or  less  regularly  at  intervals 
of  a  few  years.  Their  individual  attacks  usually  do  not 
differ  materially  from  those  of  the  ordinary  recurrent  type, 
or  the  single  isolated  attack  of  a  lifetime  (which  by  the 
way  is  very  rare,  the  majority  of  the  single  attacks, 
commonly  dubbed  mania,  being  cases  of  amentia),  but 
they  very  frequently  manifest  more  or  less  systematized 
delusions  of  paranoidal  type  (vide  p.  61),  which,  more 
prominent  during  their  periods  of  excitement,  are  never 
quite  in  abeyance  in  their  so-caEed  normal  years. 

It  is  not  improbable  that  in  these  patients  a  paranoical 
temperament  co-exists  with  the  manic-depressive-  dia- 
thesis (vide  p.   172). 

Those  cases  which  manifest  delusions  of  a  pleasant, 
more  or  less  grandiose  nature  are  easily  distinguished  as 
maniacs,  because  their  ideas  are  in  accordance  with  the 
exuberance  and  exhilaration  present  in  that  disease, 
the  difference  from  ordinary  maniacal  attacks  merely 
being,  that  the  ideas  usually  transitory  and  disconnected 
have  become  fixed  and  connected. 

There  are  other  types,  however,  in  which  ideas  of 
persecution  and  a  mood  of  resentment  or  even  slight 
depression  are  exhibited,  masking  in  some  degree  the 
buoyancy  of  the  maniac  ;  and  a  peculiar  mixture  of 
maniacal,  melancholic  and  paranoidal  features  is  pre- 
sented. 

The  maniacal  basis,  however,  colours  even  the  para- 


16  COMMON  TYPES  OF  INSANITY 

noidal  persecutory  delusions  with  a  certain  egoistic 
self-importance,  so  that  the  patient,  though  persecuted, 
is  not  afraid,  nor  really  unhappy,  but  rather  flattered 
at  the  attention  he  thinks  he  excites,  and  inclined  to 
imagine  that  he  is  a  greater  personage  than  he  was  pre- 
viously aware  of.  The  delusions  are  connected,  highly 
improbable,  but  never  intrinsically  impossible  under  every 
conceivable  combination  of  circumstances.  There  is 
complete  collectedness,  and  good  memory.  Hallucin- 
ations are  absent. 

These  cases  are  sometimes  difficult  to  diagnose  in 
their  quieter  periods,  but  when  properly  developed, 
they  are  distinguished  from  all  other  delusional  states  by 
the  presence  of  the  characteristic  signs  of  mania,  viz. 
true  intellectual  and  emotional  excitement  with  flight  of 
ideas,  and  proportionate  motor  unrest,  hyper-acute 
passive  attention,  defective  voluntary  attention,  diverti- 
bility  (except  as  regards  the  truth  of  the  delusions), 
disconnected  speech,  together  with  complete  collectedness 
and  good  memory. 

The  reader  is  advised  to  re-read  these  notes  after 
considering  the  chapter  devoted  to  delusional  states. 

Differential  Diagnosis  of  Mania  will  be  discussed  un- 
der subsequent  headings. 

Treatment 

The  patient  should  be  put  to  bed  in  a  room  containing 
no  bedstead,  nor  any  dangerous  or  breakable  articles. 
Except  in  the  worst  cases,  friendly  persuasion  can  do 
wonders  with  maniacs.  If  they  cannot  be  coaxed  to 
remain  in  bed,  as  a  rule  they  can  be  induced  to  refrain 
from  active  mischief. 

When  called  to  a  case,  observe  that  the  bladder  is  not 
distended  ;    give  an  aperient,  e.  g..  4  or  5  grains  each  of 


MANIA  17 

calomel  and  jalapin,  and  when  examining  the  physical 
condition  of  the  patient,  remember  to  test  the  urine.  As 
soon  as  the  bowels  have  acted,  sulphonal  should  be 
aclministered — 20  grains  for  a  man,  15  for  a  woman, 
twice  daily.  It  may  be  given  suspended  in  mucilage, 
or  preferably  as  a  powder,  followed  by  half  a  pint  of 
hot  milk. 

After  two  or  three  days  the  drug  should  be  discontinued 
for  one  day,  then  exhibited  again  for  another  two  or 
three,  and  stopped  again  for  two  days — and  so  on  until 
the  attack  subsides.  In  addition,  paraldehyde  in  1 
or  2  drachm  doses  may  be  administered  between  the 
doses  of  sulphonal,  and  at  night  if  necessary. 

The  food  in  mania  should  be  nourishing  and  easily 
digested,  but  no  special  dietary  is  indicated. 

Under  the  above  regime  the  majority  of  cases  are  both 
controlled  and  enabled  to  sleep.  Very  violent  patients, 
however,  may  need  an  occasional  dose  of  hyoscine 
hydrobromide  hypodermically.  Eight  minims  of  1  in 
800  solution  is  a  safe  dose,  and  may  be  repeated  in  three 
hours  if  required.  But  unmanageable  maniacs  as  a  rule 
mean  a  feeble  physician. 

Of  course,  all  sedatives  must  be  given  in  accordance 
with  general  medical  principles.  They  are  contra- 
indicated  in  serious  bodily  illness  and  feebleness — with 
some  exceptions.  Sulphonal  must  not  be  used  if  renal 
or  alimentary  diseases  or  constipation  be  present,  nor 
hyoscine  in  cardio-vaseular  disease  or  senility. 

Chloralamide,  paraldehyde,  and  morphia  are  safe, 
and  may  be  of  service.  Morphia,  however,  may  some- 
times increase  the  excitement  of  maniacs. 

A  maniacal  patient  should  be  examined  daily  for 
injuries,  and  also  after  any  struggle,  especial  attention 
being  paid  to  the  ribs.  He  should  be  persuaded  to  walk, 
and  if  any  unsteadiness  of  gait  manifests  itself,  the  sul- 

b.m.d.  2 


18  COMMON  TYPES   OF  INSANITY 

phonal  must  be  stopped  until  this  symptom  disappears. 
Care  must  be  always  taken  that  the  bowels  are  kept 
open  to  allow  the  ehmination  of  that  drug. 

The  urine  of  patients  on  sulphonal  should  be  seen  daily, 
and  if  any  darkening  in  colour  be  noted,  tested  for 
haematoporphyrin.  If  the  latter  is  present,  stop  the 
sulphonal  at  once,  and  treat  for  poisoning.  The  writer 
has  never  seen  symptoms  of  sulphonal  poisoning  arise 
from  the  doses  advocated  here,  but  idiosyncrasy  is 
said  to  exist  in  some  persons,  in  whose  case  small  doses 
produce  toxaemic  symptoms. 

Chronic  maniacs  can  be  kept  on  20  grains  of  sulphonal 
daily  for  an  indefinite  period  without  harm,  provided 
the  drug  is  discontinued  for  a  few  days  at  intervals  of  a 
week  or  so,  and  the  bowels  are  kept  open. 

An  excellent  treatment  for  many  forms  of  excitement, 
which  enables  one  to  dispense  in  a  large  measure  with 
sedatives,  is  the  continuous  warm  bath ;  but  in  the 
patient's  home,  as  well  as  in  many  asylums,  no  apparatus 
for  this  is  available.  The  temperature  of  the  water 
should  be  98°  F.,  and  the  period  in  the  bath  increased 
from  half  an  hour  on  the  first  day  to  five  hours  on  the 
seventh. 

Some  cases  of  acute  mania  terminate  in  a  short  attack 
of  exhaustion.  One  must  be  prepared  for  this  contin- 
gency, and  when  it  arises,  replace  sedatives  by  stimulants 
such  as  strychnine  and  alcohol.  Not  uncommonly 
instead  of  exhaustion,  an  attack  of  depression  or  stupor 
supervenes. 

2.     EXCITED  PHASES  IN  DEMENTIA 
PRECOX 

Dementia  Praecox  is  a  form  of  insanity  occurring 
chiefly  in  adolescents  and  tending  to  permanent  dementia 


EXCITEMENT  IN  DEMENTIA  PRECOX        19 

of  a  characteristic  type.  The  aetiology  is  obscure,  but  it 
has  been  suggested  with  some  degree  of  probability 
that  the  disease  is  due  to  a  chronic  auto-intoxication  in 
so-called  degenerate  persons.  There  is  some  presumptive 
evidence  that  this  poison  arises  from  disordered  meta- 
bolism in  the  sexual  glands.  Quiet,  reserved,  egotistical 
adolescents  are  chiefly  attacked. 

A  family  history  of  insanity  is  almost  invariably 
forthcoming,  and  the  disease  is  particularly  prone  to 
attack  brothers  and  sisters. 

Dementia  prsecox  exhibits  various  forms  and  phases 
besides  excitement.  These  will  be  discussed  under 
subsequent  headings.  States  of  excitement  initiate 
some  cases,  and  occur  in  the  majority  during  the  course 
of  the  disease. 


Symptoms  of  Excitement  in  Dementia  Praecox 

1.  The  motor  excitement  may  be  considerable.  The 
patient  perhaps  jumps  about,  gesticulates  and  shouts. 
He  is  often  dirty  in  habits,  destructive,  degraded,  and 
cleverly  violent.  He  grimaces,  grins  and  executes  pur- 
poseless acts.  His  conduct  has  often  a  pronounced 
sexual  colouring. 

As  a  rule  he  manifests,  in  addition,  some  definite  signs 
of  katatonia  or  catalepsy  (vide  Glossary,  pp.  2Q2,  203),  e.  g., 
rigid  attitudes,  alternating  with  causeless  violence,  or 
stereotypism  in  movements.  But  with  all  this  motor 
unrest  there  is — 

2.  Little  or  no  intellectual  or  emotional  excitation. 
The  excited  conduct  does  not  appear  sincere,  owing  to 
the  co-existence  of  a  fundamental  and  characteristic 
emotional  dullness. 

3.  Disjointed,  meaningless,  and  absurd  speech ;  a 
degree  of  incoherence  is  present  out  of  all  proportion 


20  COMMON  TYPES  OF  INSANITY 

to   the   excitement.     Verbigeration,  i.  e.,   the   continual 
repetition  of  one  word  or  phrase,  is  common. 

4.  Comprehension,  perception,  and  memory  are  good, 
and  there  is  no  true  disorientation  (vide  Glossary). 

5.  Divertibility  is  absent,  on  the  contrary,  the  reverse 
is  often  manifest,  viz.,  negativism,  a  chronic  impulse  to 
do  the  exact  opposite  of  what  is  suggested. 

6.  Auditory  hallucinations  are  exceedingly  common,  if 
not  present  in  every  case,  "and  visual,  tactile,  coenesthetic 
hallucinations  are  not  uncommon.  Shifting  transitory 
delusions  of  grandeur  or  persecution  or  of  an  impersonal 
nature  accompany  the  hallucinations.  The  erroneous 
ideas  are  often  intrinsically  absurd  and  impossible. 


Prognosis 

These  attacks  of  excitement  are  short,  usually  of  only 
a  few  days'  or  weeks'  duration.  Those  which  apparently 
initiate  the  disease  sometimes  result  in  almost  complete 
recovery,  but  the  mischief  is  merely  latent,  and  further 
developments  are  certain.  Usually,  however,  some 
abnormality  remains  after  the  subsidence  of  the  excite- 
ment, varying  from  simple  dulling  of  interest  in  life,  to 
definite  clinical  pictures  of  dementia  prsecox. 

Differential  Diagnosis  from  Mania 

1.  Symptoms  present  in  dementia  prsecox,  but  absent 
in  mania — 

(1)  Basic  emotional  dullness. 

(2)  Motiveless  acts,  absurd  or  degraded  conduct. 

(3)  Meaningless    talking,    and    verbigeration. 

(4)  Hallucinations. 

(5)  The  katatonic  or  cataleptic  syndrome  in  part  or 

whole  (vide  Glossary). 


EXCITEMENT  IN  DEMENTIA  PRAECOX      21 

2.  Symptoms  present  in  mania,  but  absent  in  dementia 
prsecox  :• — 

(1)  Marked  intellectual   excitement   with   flight   of 

ideas. 

(2)  Genuine  emotional  exuberance. 

(3)  Press  of  occupation. 

(4)  Divertibility. 

(5)  Pride  or  amour  propre. 

Some  of  the  initial  states  of  excitement  in  dementia 
prsecox  approximate  more  closely  to  the  clinical  picture 
of  mania.  They  may  show  no  obvious  katatonia,  hallu- 
cinations may  be  difficult  to  make  out,  and  senseless 
speech  absent.  Careful  observation,  however,  will  soon 
indicate  the  true  condition.  Perhaps,  in  the  midst  of  a 
bout  of  violence  and  apparent  rage,  the  patient  may  smile 
vacantly.  This  vacant  smile,  guiltless  of  external  cause, 
free  from  mirth,  and  silly,  is  characteristic  of  dementia 
prsecox. 

Affectation  of  manner  uncoloured  by  humour,  pedantry, 
sudden  weeping  aloud  without  cause,  or  other  indications 
of  sham  emotions,  in  addition  to  motiveless  conduct,  are 
conclusive  evidence  of  that  disease.  Coining  new  words 
("  neologisms "),  intrinsically  absurd  and  impossible 
delusions  should  at  once  put  one  on  the  same  track. 

Finally,  it  may  be  stated  that  most  cases  of  pathological 
excitement  occurring  in  adolescence  are  manifestations  of 
dementia  prsecox. 

Treatment 

The  general  management  of  the  excitement  should  be 
conducted  on  the  same  lines  as  that  of  mania.  Moral 
suasion  however  is  useless,  as  the  patients  usually  act  in 
opposition  to  any  suggestion,  and  misconduct  themselves 


22  COMMON  TYPES  OF  INSANITY 

from  perversity.  This  is  doubtless  due  to  negativism, 
but  it  creates  an  impression  of  deliberate  malice.  Sul- 
phonal  is  not  a  good  drug  for  these  cases.  If  pushed 
it  renders  them  less  troublesome,  but  at  the  expense  of 
safety  in  dosage. 

Chloral  hydrate  in  doses  of  20  grains  t.d.  or  a  mixture 
of  bromides  and  Cannabis  Indica  answers  fairly  well  as  a 
sedative.  Nothing  seems  to  influence  the  course  of  the 
malady  of  which  this  excitement  is  an  expression.  Cases 
remain  stationary  or  degenerate  into  dementia,  in  spite  of 
any  treatment  so  far  discovered. 


3.  ACUTE  CONFUSIONAL  INSANITY 

By  this  term  is  meant  an  acute  semi-conscious  state  of 
confusion  accompanied  by  disorientation,  hallucinations, 
and  signs  of  bodily  illness,  which  terminates  in  recovery 
or  death. 

The  conditions  included  under  the  present  heading 
are,  agitated  amentia,  acute  delirium,  delirious  mania, 
delirium  of  collapse,  exhaustion  and  intoxication  psy- 
chosis. These  various  names  are  applied  to  disorders 
presenting  essentially  the  same  symptoms  in  different 
degrees  of  intensity,  acute  delirium  and  the  so-called 
delirium  of  collapse  being  the  graver  forms. 

Intoxication  is  regarded  as  the  root  cause,  and  for  its 
aetiology  the  reader  is  referred  to  the  Table  of  Classification 
on  page  ix. 

Amentia  agitata  may  be  taken  as  typical  of  excited 
forms  of  acute  conf usional  insanity ;  varieties  of  the  latter 
due  to  specific  poisons  differ  mainly  from  amentia,  in  pre- 
senting physical  signs  of  the  causative  toxins,  amentia 
being  the  result  of  an  auto-intoxication  of  unknown 
nature. 


ACUTE  CONFUSIONAL  INSANITY  23 

Symptoms  of  Amentia  Agitata 

1.  A  high  degree  of  excitement  with  great  motor 
unrest,  varying  from  constant  picking  at  bedclothes 
and  tossing  about,  to  violent  rushing  and  struggling — 
purposeless  or,  at  best,  defensive  acts  the  result  of  internal 
not  external  stimuli. 

2.  Great  confusion  of  speech.  The  talking  is  meaning- 
less and  unintelligible,  often  showing  disintegration  of 
words,  and  due  to  a  rapid  confused  flight  of  imperfectly 
developed  ideas. 

3.  Clouding  of  consciousness.  Perception  {vide  Glos- 
sary) is  confused  and  inhibited.  The  patient  is  engrossed 
in  himself  and  has  very  little  consciousness  of  his  sur- 
roundings. He  is  in  a  large  measure  impervious  to 
external  impressions.  Passive  attention  is  absent ;  dis- 
orientation in  time  and  space,  of  course,  present. 

4.  Emotionally,  agitation  and  apprehension  predom- 
inate, but  there  are  rapid  changes  ;  the  patient  may  be 
terrified,  amorous,  and  hilarious  in  turn. 

5.  Hallucinations  are  incessant,  and  dominate  the 
entire  picture  ;  the  patient's  mind  is  mainly  occupied 
with  these. 

6.  There  may  be  loss  of  the  sense  of  personal  identity. 

7.  The  onset  is  always  acute. 

8.  Brief  lucid  intervals. 

9.  Physical  signs  of  illness,  varying  from  anaemia  and 
emaciation  to  a  grave  typhoid  state. 

10.  On  recovery,  amnesia  for  incidents  occurring  during 
the  attack. 

Prognosis 

These  cases  either  recover  completely,  or  die.  Physical 
recovery  involves  mental  cure.  The  main  cause  of  death 
is  collapse,  which  may  occur  within  a  few  days  of  the  onset 


24  COMMON  TYPES  OF  INSAOTTY 

of  the  delirium.  Continuous  fever  is  of  bad  prognostic 
significance,  so  also  is  a  "  typhoid-state."  Dirty,  de- 
graded and  destructive  habits  are  said  to  be  indicative 
of  a  serious  attack,  and  the  outlook  is  also  considered 
worse  in  cases  manifesting  remissions  lasting  for  some 
days. 

Finally,  some  patients  are  said  to  have  more  or  less 
periodical  attacks  at  intervals  of  some  years. 

Differential  Diagnosis 

(a)  Feom  Mania  : — 

1.  Signs  present  in  amentia   agitata   and  absent  in 

mania  : 

(1)  Abrupt  onset. 

(2)  Semi-consciousness,    with   inhibited    perception, 

complete    disorientation    and    great    confusion. 

(3)  Incessant  hallucinations. 

(4)  Confusion  of  speech,  i.  e.,  fragmentary,  senseless 

talking. 

(5)  Apparently  purposeless  conduct. 

(6)  Rapid  emotional  changes,  arising  from  within. 

Apprehension,  when  present. 

(7)  Physical  signs  of  bodily  illness. 

2.  Signs   present   in   mania    and    absent   in    amentia 

agitata  — 

(1)  Hyper  sensitiveness  to  external  impressions,  with 

keen  passive  attention. 

(2)  Accessibility  and  divertibility  (vide  Glossary). 

(3)  General  alertness,  and  good  comprehension  and 

memory. 

(b)  From   Excitement  in  Dementia  Precox  : — 

1.  Signs  present  in   amentia   agitata   and   absent  in 
dementia  prsecox  : — 


ACUTE  CONFUSIONAL  INSANITY  25 

(1)  Semi-consciousness     with    inhibited    perception 

and  complete  disorientation. 

(2)  Genuine  intellectual  excitement,  with  flight  of 

ideas. 

(3)  Deep  and  sincere  emotional  states. 

(4)  Physical  signs  of  bodily  illness. 

2.  Signs  present  in  dementia  prsecox  and  absent  in 
amentia  agitata  : — 

(1)  Basic  emotional  vacuity. 

(2)  Katatonia  or  catalepsy,  in  some  form  (but  see 

p.  183). 

(3)  Good  comprehension  and  memory. 

Treatment 

It  must  be  continually  borne  in  mind  that  the  patient  is 
gravely  ill. 

On  receiving  a  case  of  confusional  excitement,  be  pre- 
pared for  signs  of  fevers,  uraemia,  drug  poisonings, 
meningitis,  etc.  These,  if  present,  should  be  treated  as 
far  as  possible  on  general  lines. 

See  that  the  bladder  is  not  distended,  test  the  urine, 
take  the  temperature,  if  possible,  and  examine  the  patient 
physically.  These  patients  are  not  suitable  for  treatment 
in  their  homes.  The  patient  should  be  put  into  an 
asylum,  and  into  a  padded  room,  empty  except  for  mat- 
tress and  bedclothes.  The  door  must,  of  course,  be  open, 
and  a  nurse  stationed  at  it.  There  are  five  essentials  to  be 
aimed  at  in  treatment. 

1.  To  feed  the  patient. 

2.  To    procure  rest  and  sleep. 

3.  To  prevent  injury. 

4.  To  keep  the  bowels  and  kidneys  active. 

5.  To  keep  the  patient  clean. 

1.  Food. — Milk,  eggs,  beef -tea,  and  other  nourishing 


26  COMMON  TYPES   OF  INSANITY 

fluids  should  alone  be  given.  If  the  patient  will  not  eat, 
he  must  be  fed  by  the  stomach  tube  without  delay.  If 
he  is  feeble,  give  digitalin  and  strj^chnine  hypodermically 
before  the  feed.  Then  wash  out  the  stomach  with  saline, 
and  afterwards  administer  the  following  mixture : — 
Milk  (warm),  1 J  pints  ;  2  eggs  ;  1  oz.  sugar  ;  Valentine's 
meat  juice,  2  drachms  ;    brandy,  1  oz. 

A  similar  feed  must  be  repeated  three  times  a  day, 
necessary  medicine  being  added  when  required.  If  the 
stomach  does  not  retain  approximately  the  necessary 
quantity,  the  latter  must  be  reduced,  the  strength 
diluted,  and  the  feeding  be  more  frequent. 

In  very  severe  cases,  which  cannot  retain  any  food, 
Dr.  Stoddart  recommends  the  administration  of  chloro- 
form for  tube  feeding,  the  anaesthetic  being  kept  going  for 
one  hour  after  the  feed. 

Bad  cases  need  stimulants.  Brandy  is  probably  the 
best,  and  may  be  given  in  one  or  two  ounce  doses  every 
three  or  four  hours. 

2.  Rest  and  Sleep. — It  is  often  exceedingly  difficult 
to  procure  sleep  for  these  patients.  The  use  of  sedatives 
is  necessarily  limited  owing  to  the  danger  of  collapse. 
Continuous  warm  baths  as  described  for  mania  are  useful, 
but  care  must  be  taken  that  they  do  not  further  exhaust 
the  patient.  Sulphonal,  trional,  veronal,  etc.,  should 
not  be  given  ;  chloral  and  bromides  are  not  recommended. 
Paraldehyde  is  perhaps  the  best  drug.  It  may  be  given 
in  1 1  or  2  drachm  doses  every  four  hours,  but  unfortu- 
nately it  soon  loses  its  effect.  In  the  majority  of  cases, 
chloralamide  may  also  be  quite  safely  used  in  doses  of  10 
to  15  grains.     Morphia  and  its  allies  may  be  of  value. 

Brandy  is  soothing,  as  well  as  a  cardiac  stimulant, 
and  is  a  useful  auxiliary  sedative  in  somewhat  larger 
doses  than  those  mentioned  above. 

3.  Immunity  from  Injury. — This  is  obtained  by  the 


ACUTE  CONFUSIONAL  INSANITY  27 

use  of  a  padded  room  and  the  attendant  at  the  door. 
The  patient  should,  of  course,  be  examined  daily. 

4.  Active  Bowels  and  Kidneys. — If  the  patient 
is  not  too  excited  an  enema  should  be  given  on  admission. 
If  it  is  not  effectual  it  must  be  repeated  in  two  hours. 
When  one  has  information  that  the  bowels  have  acted 
within  the  previous  three  days,  an  aperient  may  be 
administered,  preferably  calomel.  If  neither  an  enema 
nor  aperient  can  be  given,  and  the  bowels  do  not  act  in 
twenty-four  hours,  the  patient  must  be  fed  by  tube  with 
a  purgative,  e.  g.,  emulsion  of  castor  oil  (1  in  2)  in  a  pint 
of  warm  milk.  If  vomiting  occurs,  and  the  bowels  still 
remain  obstinate,  chloroform  must  be  resorted  to  as  sug- 
gested above  ;  the  stomach  washed  out  ;  a  feed,  and 
aperient  given  by  tube,  the  bowels  being  cleared  out  at 
the  same  time. 

The  action  of  the  kidneys  may  be  promoted  by  giving 
plenty  of  barley  water,  if  possible.  Rectal  injections 
have  been  found  of  value  in  cases  that  retain  them. 

5.  Cleanliness,  Internal  and  External. — In  addi- 
tion to  the  hints  under  the  preceding  heading,  which 
make  for  internal  cleanliness,  the  mouth  and  teeth  must 
be  scrupulously  attended  to.  After  each  meal,  the  teeth 
and  gums  should  be  swabbed  over  with  some  innocuous 
antiseptic,  such  as  glycerine  acid  boric  and  hydrogen 
peroxide. 

The  administration  of  lactic  acid  organisms,  several 
preparations  of  which  are  on  the  market,  should  prove 
useful  in  lessening  intestinal  intoxication  but  it  must  be 
remembered  that  these  tend  to  produce  constipation. 

The  skin  of  the  back,  and  other  parts  of  the  body 
liable  to  pressure,  should  be  painted  with  some  hardening 
preparation,  e.  g.,  a  paste  made  of  zinc  oxide,  starch, 
and  dilute  methylated  spirit.  This  should  be  a  routine 
procedure  three  times  daily,  additional  paintings  following 


# 


28  COMMON  TYPES  OF  INSANITY 

all  washing  of  the  patient.  The  latter  is  necessarily 
frequent,  as  these  cases  are  almost  invariably  "  wet  and 
dirty." 

Collapse,  should  it  occur,  must  be  treated  on  general 
medical  lines,  by  stimulants,  saline  infusions,  pituitarin, 
etc. 

Finally,  the  patient  should  be  confined  to  bed  for  a 
week  or  more,  after  the  attack  has  subsided,  preferably 
in  the  open  air,  and  strengthened  by  abundant  nourishing 
foods  and  tonics. 


4.  STATES  OF  EXCITEMENT  IN  GENERAL 
PARALYSIS  OF  THE  INSANE 

Phases  of  excitement  may  occur  at  what  is  regarded 
as  the  onset  of  the  disease,  at  intervals  during  its  progress, 
or  may  constitute  the  entire  clinical  course. 

The  recurrent  attacks  are  sometimes  followed  by 
remissions  of  some  months'  duration,  but  the  patient 
deteriorates  mentally  after  each. 

The  disease  occasionally  takes  the  form  of  a  continuous 
state  of  excitement,  resulting  in  death  in  a  few  months. 
This  is  so-called  "galloping  G.P.I."  The  excitement  in 
G.P.I,  is  often  of  mixed  type,  but  for  convenience  in 
diagnosis  two  main  varieties  may  be  described. 

(A)  MANIACAL  EXCITEMENT  IN  G.P.I. 

As  the  name  implies,  this  variety  in  a  general  way 
resembles  mania,  therefore  the  distinctions  from  that 
affection  alone  need  be  given.  The  above  noted  attacks 
with  remissions  are  not  infrequently  of  this  type,  thus 
increasing  the  general  similarity  between  the  two  affec- 
tions. 


EXCITEMENT  IN  G.P.I  29 

1.  Distinctions  from  Mania 

1.  In  G.P.I,  there  is  relative  emotional  dullness,  pro- 
ducing a  disproportion  between  the  depth  of  emotion  indi- 
cated by  the  statements,  conduct,  and  general  demeanour. 

2.  The  paralytic  has  feeble  volition,  and  a  weak 
changeability  of  mood.  He  is  more  divertible  than  the 
maniac,  both  in  conduct  and  emotional  tone,  being  easily 
moved  from  laughter  to  tears.  He  has  no  increase  of 
passive  attention,  but  on  the  contrary,  marked  deficiency 
with  a  generally  decreased  reaction  to  external  stimuli. 

3.  Absurd  disconnected  delusions  of  grandeur  of  ex- 
pansive type,  i.  e.,  amplified  to  overcome  suggested  objec- 
tions, are  almost  invariably  present  in  excited  paralytics. 
Maniacs  may  have  similar  delusions,  but  they  are  not  so 
obviously  absurd,  and  owing  to  the  maniac's  flight  of 
ideas,  hardly  ever  expansive  ;  moreover,  they  are  usually 
transitory  fancies  of  doubtful  certitude,  not  delusional 
convictions. 

4.  Obvious  evidence  of  the  invariable  intellectual 
deterioration  characteristic  of  G.P.I. ,  such  as  retarded 
perception  and  ideation,  defective  memory  for  times  and 
dates,  inability  to  do  simple  sums,  etc.,  often  exists,  even 
in  the  early  states  of  excitement.  Occasionally  complete 
disorientation  is  present,  which  is  never  the  case  in  un- 
complicated mania. 

5.  From  the  above  symptoms  it  will  be  apparent  that 
in  G.P.I,  there  is  none  of  the  keen  alertness  of  the  maniac, 
on  the  contrary  a  general  air  of  futility  and  ineffective- 
ness pervades  the  demeanour  and  conduct  of  the  excited 
paralytic. 

6.  Some  physical  signs  of  G.P.I,  are  usually  present. 
Amimia  in  the  lower  part  of  the  face  can  often  be  made 
out  when  the  motor  excitement  precludes  the  examination 
of  reflexes,  etc. 


30  COMMON  TYPES  OF  INSANITY 

In  a  word,  it  is  the  signs  of  the  degenerative  process 
both  mental  and  physical  in  G.P.I,  that  form  the  basis 
of  the  distinctions  between  its  excited  phase,  and  mania. 


2.  Diagnosis  of  Maniacal  Excitement  in  G.P.I. 
from  that  in  Dementia  Praecox 

There  is  usually  no  difficulty  in  distinguishing  between 
these  two  conditions,  though  the  symptoms  appear  some- 
what similar  on  paper.  The  following  are  the  chief  points 
to  be  noticed  :— 

In  G.P.I,  are  present : 

1.  Marked  divertibility  of  mood  and  conduct,  insta- 
bility of  emotional  state,  euphoria  and  exaltation  pre- 
dominating. 

2.  More  continuous  motor  excitement  and  restlessness. 

3.  Genuine,  though  superficial  emotional  states. 

4.  Expansive  delusions. 

5.  Paralytic  demential  symptoms  (vide  supra)  and 
physical  signs  (vide  p.  99.) 

6.  With  regard  to  conduct,  the  paralytic's  actions  are 
disproportionate  to  his  emotional  state  or  ideas,  but  not 
motiveless. 

In  dementia  prsecox  are  present : 

1.  Meaningless  remarks  or  unintelligible  talking. 

2.  Katatonia.1 

3.  Purposeless  acts. 

1  Some  excited  paralytics  strike  attitudes,  indulge  in  silly 
antics,  are  transitorily  negativistic  ;  and  generally  play  the  fool. 
But  the  picture  of  katatonia  is  not  complete  ;  it  is  marred  by 
the  essential  futility  of  the  paralytic,  who,  as  it  were,  cannot  be 
katatonic  efficiently.  He  can  be  persuaded  out  of  his  nega- 
tivism ;  his  euphoria  will  obtrude  itself,  and  his  antics,  etc.,  are 
rather  the  result  of  his  euphoria,  or  of  a  desire  for  display  and 
parade,  than  of  a  blind  internal  impulse  as  in  the  case  of  de- 
mentia praecox. 


EXCITEMENT  IN  G.P.I  31 

4.  Apparently  deliberate,  malicious  and  unprovoked 
misconduct. 

5.  Auditory  hallucinations  (cf.  paralytic  delirium). 


3.  Distinctions  from  Acute  Confusional  Insanity 

The  form  of  paralytic  excitement  under  consideration 
is  not  likely  to  be  confounded  with  amentia.  The  con- 
fused dreamlike  condition  with  the  constant  hallucina- 
tions and  self-absorption,  together  with  the  physical 
signs  of  illness  are  distinctive  signs  of  the  latter.  Add  to 
these  the  genuinely  lively  emotional  state  of  the  ament, 
the  complete  disorientation,  absence  (except  very  transi- 
torily) of  euphoria  ;  and  one  has  a  clinical  picture  quite 
unlike  maniacal  G.P.I. 

(B)  PARALYTIC  DELIRIUM 

This  state  is  probably  to  be  looked  upon  as  an  intoxica- 
tion syndrome  or  amential  episode  occurring  in  the  course 
of  general  paralysis.  Hence  its  symptomatology  resem- 
bles more  or  less  closely  that  of  acute  confusional  insanity. 
The  following  are  useful  points  in  distinguishing  the 
paralytic  variety  : — 

1.  A  slighter  degree  of  clouding  of  consciousness  and 
confusion,  with  greater  accessibility,  which  may  enable 
one  to  demonstrate  : 

2.  Divertibility  of  mood  and  conduct. 

3.  A  much  less  lively  and  less  deep  emotional  state, 
with  more  continuous  exaltation  and  little,  if  any,  appre- 
hension. 

4.  More  intelligible  speech. 

5.  An  undercurrent  of  euphoria  colouring  all  moods, 
flaring  out  at  times  in  the  form  of  absurd  grandiose 
delusions. 

6.  Less  prominent  hallucinations, 


32  COMMON  TYPES  OF  INSANITY 

7.  Less  rapid  ideation. 

8.  Absence  of  marked  cachexia  (except  in  long- 
standing cases  of  G.P.I,  in  which  the  history  or  previous 
knowledge  of  the  case  precludes  any  doubt  about  the 
diagnosis)  and  the  presence  of  physical  signs  of  G.P.I. 

9.  Short  duration,  a  few  hours  or  days. 

The  galloping  variety  of  G.P.I,  not  infrequently 
shows  phases  of  delirium,  in  which  case  the  distinctions 
from  amentia  given  under  sections  8  and  9  do  not  apply. 

Prognosis 

The  nature  of  the  attacks  of  excitement  has  been  briefly 
outlined  at  the  beginning  of  this  section.  G.P.I,  itself 
is  at  present  an  incurable  disease,  and,  moreover,  usually 
fatal  in  three  years.  The  galloping  form  has  been  referred 
to.  The  variety  taking  the  form  of  a  series  of  more  or 
less  isolated  attacks,  may  extend  over  ten  years. 

Treatment 

The  treatment  of  excitement  in  G.P.I,  is  much  the  same 
as  that  of  mania  and  acute  confusional  insanity.  Special 
attention  should  be  paid  to  the  skin,  and  the  fragility 
of  the  bones  in  some  paralytics  must  be  borne  in  mind. 
Difficulty  in  deglutition  or  a  tendency  to  bolt  food — 
involving  a  risk  of  choking — must  be  guarded  against 
by  restricting  the  diet  to  slops,  and  if  necessary,  by  feeding 
the  patient  with  a  spoon. 

For  the  various  methods  that  have  been  recommended 
for  the  treatment  of  the  disease  per  se,  more  detailed 
works  must  be  consulted.  Since  the  discovery  of  the 
spirochseta  pallida  in  the  brains  of  paralytics  and  the 
direct  application  of  anti-syphilitic  remedies  by  subarach- 
noid or  intrathecal  injection  the  prospect  of  finding  a 
cure  has  been  improved. 


DELIRIUM  TREMENS  33 

5.  DELIRIUM  TREMENS 

Delirium  tremens  is  a  form  of  acute  conf usional  insanity 
occurring  in  chronic  alcoholics  as  the  result  of  a  secondary 
auto-intoxication,  generally  regarded  as  induced  by  an 
over-production  of  anti-bodies  to  alcohol. 

It  does  not  always  take  the  typical  form  described 
below.  Masked  epilepsy  is  sometimes  co-existent  with 
chronic  alcoholism :  this  coincidence  is  well-known 
in  the  case  of  dipsomania,  and  it  is  occasionally  seen  in 
delirium  tremens. 

Great  stupefaction,  blind  violence,  and  also  convulsions, 
(unless  these  latter  are  due  to  uraemia)  may  be  indications 
that  the  patient  is  also  subject  to  epilepsy  at  other  times, 
but  such  is  not  a  necessary  deduction. 


Symptoms 

1.  Gradual  onset,  with  restless  apprehension  and  iso- 
lated elementary  visual  hallucinations. 

2.  Motor  excitement,  the  result  of  apprehension. 

3.  Rambling,  but  intelligible  speech,  often  blurred  and 
tremulous. 

4.  Some  clouding  of  consciousness.  Real  perceptions 
are  mingled  with  false,  so  that  the  semi-consciousness  is 
not  deep,  but  disorientation  is  present. 

5.  Accessibility,  except  in  the  very  worst  periods  of 
grave  cases. 

6.  Divertibility  (subject  of  course  to  5)  in  mood, 
thought  and  action.  The  attention  can  be  temporarily 
distracted  from  imaginary  delirious  events  and  hallucin- 
ations, to  the  immediate  surroundings. 

7.  Numerous  vivid  hallucinations,  chiefly  visual,  and 
often  taking  the  form  of  reptiles,  vermin,  devils,  etc., 
fantastic  dream-like  illusions  and  delusions. 

E.M.D.  3 


34  COMMON  TYPES  OF  INSANITY 

8.  A  mingled  apprehensive  and  humorous  mood. 

9.  Frequent  brief  lucid  intervals,  during  which  the 
patient  is  clear  and  collected  and  understands  his  condi- 
tion, treats  it  as  a  joke,  but  is  really  rather  frightened. 
He  knows  the  nature  of  his  surroundings,  but  is  confused 
about  time.  His  memory,  except  for  the  period  of  his 
delirium  is  good.  These,  be  it  understood  during  the 
lucid  periods. 

10.  Physical  signs  of  alcoholism  :  e.g.,  coarse  tremor  of 
hands,  lips  and  tongue,  flushed  face,  sweating,  smell  of 
alcohol.     None  of  these  signs  are  invariably  present. 

Prognosis 

The  majority  of  cases  recover  completely  in  a  few 
days,  usually  after  a  long  sleep.  About  4  per  cent,  die, 
chiefly  of  pneumonia,  heart  failure  or  ursemic  convulsions. 
In  some  patients  the  acute  symptoms  subside  but  leave 
some  other  alcoholic  syndrome  in  their  wake  (vide  infra). 
Relapses  sometimes  occur  after  some  days  of  lucidity, 
and  recurrences  at  intervals  of  months  or  years  are 
extremely  common. 

Differential  Diagnosis 

Of  the  forms  of  excitement  already  discussed,  only 
two  are  at  all  likely  to  be  confused  with  delirium  tremens, 
namely  amentia  agitata  and  paralytic  delirium — them- 
selves varieties  of  acute  intoxication  insanity.  The 
following  features  of  delirium  tremens  are  useful  in  this 
connexion  : 

1.  Predominance  of  visual  hallucinations,  usually  of 
the  characteristic  type. 

2.  The  slighter  degree  of  clouding  of  consciousness, 
the  mingling  of  true  and  false  impressions. 

3.  Greater    accessibility.     The    delirious    paralytic    if 


DELIRIUM  TREMENS  35 

sufficiently  accessible,  is  divertible  in  mood  and  conduct, 
but  cannot  be  awakened  and  caused  to  bring  his  mind  to 
bear  upon  the  actual  status  quo.  The  ament  is  inacces- 
sible. Neither  can  be  made  to  understand  their  situation 
or  condition. 

4.  The  completeness  and  frequency  of  the  lucid  inter- 
vals. In  these,  the  alcoholic  and  the  ament  have  a  sense 
of  illness,  and  an  insight  into  their  condition  :  the  para- 
lytic shows  defective  auto-criticism  at  all  times. 

5.  Quite  intelligible,  though  disconnected  talking. 

6.  The  gradual  and  characteristic  onset. 

7.  The  presence  of  signs  of  alcoholism,  and  absence  of 
physical  signs  of  G.P.I,  or  of  severe  bodily  illness  (when 
such  is  the  case). 

8.  The  preservation  of  the  sense  of  personal  identity, 
which  is  sometimes  absent  in  the  other  two  conditions, 
e.g.,  the  ament  may  think  he  is  a  spot  on  the  wall,  or  a 
cloud  ;    the  paralytic,  a  god. 

9.  Much  greater  apprehension  when  at  its  worst,  than 
ever  occurs  in  paralytic  delirium. 

Treatment 

The  general  management  is  the  same  in  all  confusional 
states.  In  the  alcoholic  form,  it  is  advisable  to  give 
milk  only,  in  order  to  spare  the  kidneys  (often  already 
functioning  badly)  as  much  work  as  possible.  Stimulants, 
other  than  alcohol,  should  be  used  if  required,  especially 
strychnine  and  caffeine. 

A  brisk  calomel  purge  at  the  onset,  followed  by  a 
saline,  should  never  be  omitted. 

These  patients  are  sometimes  prone  to  impulsive 
suicidal  attempts,  e.g.,  they  may  jump  out  of  a  window 
to  escape  from  hallucinatory  terrors.  If  thwarted,  and 
occasionally  when  not,  they  are  violent, 


36  COMMON  TYPES   OF  INSANITY 

To  combat  insomnia,  chloralamide  is  useful  in  20  grain 
doses,  or  amm.  bromide  grains  30  with  a  drachm  or 
two  of  paraldehyde.  They  are  best  given  at  night,  but 
may  be  ordered  t.d.  if  required.  A  drachm  or  two  of 
paraldehyde  can  always  be  administered  a  couple  of 
hours  afterwards  if  needed. 

In  all  intoxication  psychoses,  more  especially,  it  is 
better  to  dispense  with  sedatives  altogether  if  possible, 
because  the  patient  is  already  poisoned,  and  to  substitute 
the  continuous  warm  bath,  aperients,  etc.,  but  unfortu- 
nately, this  counsel  of  perfection  is  seldom  practicable. 

In  any  case,  powerful  poisons  such  as  sulphonal,  vero- 
nal, hyoscin,  should  be  avoided,  except  as  a  last  resort. 

In  general  hospitals,  hyoscine  hypodermically  may  be 
necessary.  If  the  heart  is  good,  chloral  hydrate  com- 
bined with  bromides  and  sal  volatile  and  nux  vomica, 
forms  a  useful  mixture.  It  cannot  perhaps  be  emphasized 
too  often  that  delirium  tremens  patients  are  seriously  ill, 
and  yet  eminently  recoverable.  Death  in  uncomplicated 
cases  almost  invariably  indicates  faulty  management. 


6.  ALCOHOLIC  PSEUDO-PARESIS 

This  condition  is  a  form  of  alcoholic  insanity  allied 
to  delirium  tremens  and  resembling  more  or  less  closely 
in  its  symptomatology  general  paralysis.  The  duration 
is  a  few  months  and  the  termination  complete  recovery, 
a  tendency  to  relapses,  however,  remaining  as  in  the  case 
of  all  recoverable  alcoholic  syndromes. 

Symptoms 

1.  Sudden  onset,  usually  after  middle  life. 

2.  Clouding  of  consciousness,  with  defective  percep- 
tion, and  disorientation. 


ALCHOLIC  PSEUDO-PARESIS  37 

3.  Incoherent  speech. 

4.  Euphoria  and  expansive  grandiose  delusions. 

5.  Visual  hallucinations,  often  of  similar  type  to  those 
of  delirium  tremens. 

6.  Physical  signs  of  alcoholism. 

7.  Sometimes  convulsions. 

8.  Rapid  wasting. 

This  syndrome  would  appear  to  be  another  variety  of 
amential  episode  occurring  in  the  course  of  chronic 
alcoholism,  one  approximating  more  closely  to  classical 
amentia  than  does  dehrium  tremens. 

It  is  rare,  and  its  diagnosis  depends  mainly  on  the 
question  of  physical  signs  and  previous  history,  apart  from 
which  its  resemblance  to  a  transition  phase  between 
agitated  amentia,  and  the  paranoidal  variety  (vide  p.  81) 
is  occasionally  very  close. 

Euphoria  sufficient  to  result  in  grandiose  delusions 
does  not  often  occur  in  amentia,  nor  are  the  hallucinations 
predominately  visual.  The  latter  statement  is  also  true 
of  paralytic  dehrium. 

With  regard  to  physical  signs,  peripheral  neuritis, 
and  coarse  tremors,  when  present,  are  indications  of  the 
alcoholic  condition.  Alcoholic  tremors  are  more  common 
in  the  upper,  paralytic  tremors  in  the  lower  part  of  the 
face.  Rigid  pupils  are  rare  in  alcoholism,  common  in 
G.P.I.  Argyll-Robertson  pupils  and  increased  floppy 
knee  jerks  are  conclusive  evidence  of  the  latter. 

Nevertheless,  the  diagnosis  is  often  only  cleared  up  by 
the  course.  A  positive  Wassermann  test  in  the  cerebro- 
spinal fluid  would,  of  course,  be  in  favour  of  G.P.I,  as 
at  least  94  per  cent,  of  paralytics  manifest  this. 

Treatment 

This  should  be  carried  out  in  the  same  manner  as  in  the 
case  of  all  acute  confusional  syndromes. 


38  COMMON  TYPES  OF  INSANITY 

7.  EPILEPTIC  EXCITEMENT 

Various  forms  of  excitement'  occur  in  insane  epilep- 
tics, and  they  have,  of  course,  received  different  names. 
There  is,  however,  no  essential  difference  between  any 
of  them.  They  vary  only  in  the  depth  of  semi-con- 
sciousness present,  and  the  prominence  of  some  special 
feature  or  features.  Excitement,  motor,  intellectual,  or 
emotional,  and  some  degree  of  confusion  are  exhibited 
in  all. 

For  convenience  in  diagnosis,  only  two  forms  of  excite- 
ment, differing  from  each  other  in  the  intensity  of  the 
symptoms,  need  be  recognized.  All  chronic  epileptics 
manifest  certain  features  in  common.  These  will  appear 
as  the  varieties  of  clinical  type  of  mental  disorder  are 
described,  and  may  be  found  epitomized  under  the  heading 
of  epileptic  dementia  (p.  107). 

(A)  EPILEPTIC  DELIRIUM 

This  syndrome  resembles  amentia  agitata,  and  it  is 
probable  that  in  its  production  some  share  is  taken  by  a 
process  of  intoxication.  This  theory  is  borne  out  by  the 
relative  rarity  of  delirium  in  patients  already  under 
treatment  in  an  asylum,  where  the  bowels,  diet,  etc., 
are  attended  to  and  no  alcohol  is  obtainable.  Almost  all 
the  cases  seen  are  delirious  on  admission. 

Diagnosis 

The  following  are  the  chief  points  of  distinction  from 
amentia  agitata. 

1.  In  epileptic  delirium  : — 

(1)  There  is  deeper  stupefaction  and  clouding  of 
consciousness  with  much  more  intelligible 
speech.     The  patient  is  evidently  following  a 


EPILEPTIC  EXCITEMENT  39 

train  of  thought,  and  gives  expression  to  some 
links  in  the  chain.  There  is  no  meaningless 
speech  or  disintegration  of  words. 

(2)  Mental  processes  are  relatively  slow  and  laboured 

instead  of  showing  flight  of  ideas. 

(3)  Apprehension  is  deeper  and  more  continuous. 

(4)  Hallucinations  are  more  connected  and  terrifying, 

not  so  mutable  and  fragmentary. 

(5)  From  the  above,  it  will  be  apparent  that  the 

patient  is  less  bewildered  and  confused  than 
in  amentia,  but  yet  sutlers  from  deeper  imper- 
ception.  His  mind  is  less  chaotic,  but  more  cut 
off  from  the  external  world. 

(6)  Extreme    blind    violence    prevails,    alternating 

with  periods  of  stupor  of  some  minutes'  duration. 
Probably  the  stupor  is  the  equivalent  of  the 
lucid  intervals  of  amentia. 

Biting  of  those  who  approach  is  common. 

(7)  The  duration  is  short — a  few  hours,  or  a  day  or 

two. 

(8)  There  is  no  cachexia, 

(9)  nor,  loss  of  the  sense  of  personal  identity. 
Epileptic   delirium   may  be  excited  by  alcohol,   and 

present  features  of  delirium  tremens.  In  such  cases 
deep  clouding  of  consciousness  and  inaccessibility,  great 
violence  with  stuporose  intervals,  and  the  persistent 
absence  of  the  semi-humorous  mood,  are  the  clues  to 
the  epileptic  origin  of  the  delirium. 

Prognosis 

Apart  from  injuries  and  accidents,  the  prognosis  for 
the  individual  attacks  is  good.  The  patient  emerges  in 
a  few  hours,  or  at  most  a  day  or  two.  There  is  no  danger 
to  life. 


40  COMMON  TYPES  OF  INSANITY 

Treatment 

Shortly,  the  treatment  is  :  Padded  room,  empty  save 
for  mattress  and  bedding,  with  an  attendant  or  two  at 
the  door  :  8  mimims  of  a  1  in  800  solution  of  hyoscin 
hypodermically  and,  if  possible,  a  minim  of  croton  oil 
by  the  mouth.  (This  may  be  embedded  in  a  piece  of 
butter.)  The  injection  may  be  repeated  in  three  hours  if 
necessary. 

Diet  should  be  milk,  if  the  patient  will  take  it.  If  not, 
he  may  safely  be  left  without  food  until  he  will  feed 
himself.  These  patients  are  very  dangerous,  frequently 
homicidal,  and  sometimes  suicidal. 

(B)  EPILEPTIC  CONFUSION 

This  syndrome  is  an  "  equivalent,"  that  is,  a  condition 
substituted  for  or  associated  with  an  epileptic  convulsion, 
and  being  such,  it  is  a  more  or  less  periodical  episode 
with  many  insane  epileptics.  Under  this  heading  are 
included  epileptic  "  excitement  "  and  epileptic  "  mania." 

It  presents  much  less  clouding  of  consciousness  than 
that  last  considered.  The  patient  recognizes  people  he 
knows,  and  understands  what  is  said  to  him.  He  is, 
however,  confused  about  recent  events,  about .  time, 
and  the  general  state  of  affairs  around  him.  He  is  only 
rarely  disorientated  in  a  complete  sense,  so  far  as  places 
are  concerned,  but  he  may  only  be  able  to  say  what  sort 
of  a  place  he  is  in.  His  memory  for  recent  events  shares 
the  general  confusion ;  he  misconstrues  things,  and 
often  "  remembers  "  incidents  that  have  not  happened 
(pseudo-reminiscence).  Occasionally  hilarious  and  noisy, 
he  is  much  more  commonly  angry  or  aggrieved,  often 
imagining  he  has  been,  or  is  about  to  be,  ill-used  in  various 
ways.  These  ideas  not  infrequently  result  in  violence  ; 
at  other  times,   the  patient   simply  wanders  aimlessly 


EPILEPTIC  EXCITEMENT  41 

about.     Illusions  are  common,  hallucinations  only  spas- 
modic, indeed,  in  many  cases,  absent  altogether. 

All  mental  processes,  speech,  and  movement,  are  slow 
and  stumbling.  The  hilarious  cases  show  none  of  the 
exuberant  gaiety  of  mania. 


Prognosis 

The  duration  of  the  attack  is  usually  a  few  days,  but 
in  epileptics  of  long  standing,  and,  the  writer  cannot  help 
but  think,  in  those  kept  continually  on  bromides,  the 
confusion  may  persist  for  weeks. 

Unless  very  prolonged,  the  patients  seem  none  the 
worse  for  these  equivalents. 

Differential  Diagnosis 

Epileptic  confusion  is  distinguished  from  the  fore- 
going varieties  of  excitement,  mainly  by  the  slow  impeded 
stumbling  mentation.  The  patient's  mental  efforts  sug- 
gest attempts  at  riding  a  bicycle  whose  pedals  catch 
at  intervals,  and  with  the  brake  always  partially  on. 

This  impediment  of  thought  manifests  itself  in  the 
halting  speech,  slow  reaction  to  questions,  confused 
statements,  and  often  in  addition,  a  marked  psychomotor 
difficulty  becomes  apparent  in  inco-ordinate  articulation 
and  movements.  These  features  in  conjunction  with  the 
absence  of  combinations  of  symptoms  characteristic 
of  the  foregoing  forms  of  excitement  are  sufficient  to 
enable  a  differential  diagnosis  to  be  made. 

Treatment 

Briefly  :  Bed  in  a  single  room,  slop  diet,  and  a  smart 
purge.     It  is  desirable  to  avoid  sedatives,  but  if  this  is 


42  COMMON  TYPES  OF  INSANITY 

impossible  owing  to  continued  restlessness  and  insom- 
nia, give  chloral  hydrate  in  doses  of  20  to  30  grains  b.d. 

Bromides  should  be  discontinued  if  the  patient  is 
taking  them,  as  they  only  tend  to  intensify  and  prolong 
the  confusion.  Tact  and  kindliness  of  manner  are  very 
important  to  prevent  explosions.  (This  remark  applies 
equally  well  to  all  epileptic  states  where  any  degree  of 
consciousness  remains.)  Ask  and  persuade  epileptics, 
never  order. 

Complaints  and  charges  of  ill-treatment  are  frequently 
made  by  these  patients.  Let  them  see  that  all  such  are 
patiently  investigated,  and  thus  gain  their  confidence. 
Personal  influence  over  epileptic  patients  is  far  more 
potent  in  maintaining  good  conduct  and  quietude,  than 
all  the  drugs  in  the  pharmacopoeia. 

8.  STATES  OF  EXCITEMENT  IN  GROSS  CEREBRAL 

DISEASE 

This  section  is  limited  to  the  consideration  of  states 
of  excitement  occurring  in  cases  of  cerebral  tumour, 
abscess,  tuberculous  masses,  and  meningitis. 

The  excitement  is  thought  to  be  the  result  of  intoxica- 
tion by  products  of  neural  disintegration,  or  by  causative 
bacterial  toxins,  and  therefore  related  to  amentia. 

The  majority  of  chronic  cerebral  lesions  cause  only  pro- 
gressive dulling,  dementia,  and  physical  signs. 

There  is  no  constant  type  of  excitement  peculiar  to 
gross  brain  disease,  nor  can  the  variety  or  position  of  the 
pathological  condition  be  determined  from  the  clinical 
mental  picture.  But,  and  here  is  the  important  point, 
the  excitement  though  simulating  that  of  ordinary 
mental  disorders,  such  as  those  already  discussed,  often 
lacks  some  features  essential  and  displays  some  incon- 
gruous to  those  common  forms. 


EXCITEMENT  IN  GROSS  CEREBRAL  DISEASE    43 

It  is   only  possible   to   give   some  illustrative   cases. 

Case  I. — T.  H.,  age  35,  manifested  genuine  exaltation 
and  buoyancy.  He  was  continually  restless,  and  talked 
in  a  confused  unintelligible  manner.  Flight  of  ideas  and 
disorientation  were  present,  but  individual  perception 
was  good.  He  understood  what  was  said  to  him,  and 
sometimes  replied  correctly  to  questions  about  his  past 
life.  Active  attention  was  bad,  passive  quite  fair.  He 
was  resistive,  and  kicked  slyly  at  those  who  approached. 
He  was  obviously  confused,  and  had  no  understanding 
of  the  general  situation.  Hallucinations  were  absent. 
Now  this  condition  shows  resemblances  to  only  three  of 
the  disorders  previously  described,  namely  amentia, 
mania,  or  G.P.I.  But  obvious  discrepancies  are  mani- 
fest. 

Mania  is  excluded  by  the  oppressive  disorientation, 
meaningless  speech,  and  marked  confusion.  Amentia 
by  the  lack  of  imperception,  the  quite  good  passive 
attention,  the  accessibility,  the  continuously  cheerful 
mood,  and  the  absence  of  hallucinations. 

The  liveliness  of  the  excitement,  the  alertness5  and 
rapidity  of  mental  action,  and  the  meaningless  talk, 
taken  in  conjunction  with  the  absence  of  expansive  ideas, 
physical  signs,  and  the  general  futility  of  the  paralytic, 
prevent  one  from  adopting  a  diagnosis  of  G.P.I. 

By  a  process  of  exclusion  upon  these  lines,  the  presence 
of  some  gross  cerebral  disease  was  considered  the  most 
probable  solution.  None  of  the  ordinary  physical  signs 
of  cerebral  affections  were  apparent  (optic  neuritis 
could  not  be  determined  owing  to  the  excitement  of  the 
patient),  nor  did  the  man  at  first  appear  physically  ill. 

During  some  weeks  of  continuous  restlessness,  he 
became  gradually  more  unconscious,  and  finally  coma- 
tose. Death  occurred  within  thirty-six  hours  from  the 
onset  of  the  coma. 


44  COMMON  TYPES  OF  INSANITY 

At  the  necropsy,  tuberculous  softening  and  destruction 
was  found  in  the  left  cerebral  hemisphere. 

Case  II. — This  patient,  a  man  of  29,  was  genuinely 
excited  and  exalted.  He  laughed  and  talked  garru- 
lously, was  restless,  struck  absurd  attitudes,  and  was 
transitorily  negativistic  and  mute.  Speech  was  inco- 
herent, but  intelligible  and  characterized  occasionally 
by  intrinsically  ridiculous  statements  or  verbigeration. 
Continual  hallucinations  of  hearing  took  up  a  good  deal 
of  the  patient's  attention.  Perception  and  compre- 
hension of  conversation  were  good.  Degradation,  moral 
perversion,  obscenity  and  malicious  acts,  were  absent. 
Marked  anaemia  and  emaciation  existed,  apparently 
without  any  causative  bodily  condition. 

This  case  looked  very  much  like  katatonic  excitement, 
i.e.,  dementia  prsecox.  Here  again,  however,  close 
observation  revealed  certain  discrepancies.  The  excite- 
ment was  too  genuine,  the  restlessness  too  continued, 
and  the  general  conduct  too  sensible  and  decent,  and 
the  hallucinations  rather  too  obtrusive,  also  the  marked 
physical  illness  had  to  be  accounted  for. 

At  the  autopsy  a  tuberculous  abscess  was  found  in  the 
anterior  region  of  the  left  temporal  lobe.  In  this  case 
also  no  physical  signs  of  gross  brain  disease  could  be  made 
out  during  life. 

Case  III. — W.  Y.,  aged  62,  had  been  noisy  and 
violent  before  admission.  When  admitted  he  was  in  a 
condition  of  continuous  motor  restlessness.  He  wandered 
about  carrying  his  bedclothes,  and  paid  no  attention  to 
his  surroundings.  He  had  no  idea  of  time  or  place,  but 
his  comprehension  of  remarks  and  his  active  attention 
were  good,  and  his  mental  re-action  fairly  rapid.  He 
had  apparently  no  memory,  and  manifested  no  particular 
emotional  tone.  The  speech  showed  nothing  abnormal. 
The  physical  examination  nothing   of  importance,   but 


EXCITEMENT  IN  GROSS  CEREBRAL  DISEASE    45 

absent  knee-jerks.  The  patient  had,  however,  one  or  two 
mild  epileptic  fits  daily. 

Now  this  is  not  an  easy  case  to  diagnose.  The  first 
diagnosis  thought  was  of  epileptic  confusion.  But  such 
a  degree  of  dementia  and  amnesia  would  be  accompanied 
by  slow  stumbling  mentation,  and  the  complete  disorienta- 
tion by  a  much  deeper  clouding  "of  consciousness  and  in- 
accessibility. Moreover,  no  apprehensive,  "  wound  up," 
resentful,  or  angry  mood  was  present. 

Such  pronounced  dementia  in  G.P.I,  would  be  accom- 
panied by  physical  signs. 

Another  solution  that  presented  itself  was  a  confusional 
episode  in  a  rather  premature  case  of  senile  dementia. 
Against  this  hypothesis  are  the  continually  recurring 
fits,  the  absence  of  signs  of  senility  and  arterio-sclerosis ; 
moreover,  good  power  of  active  attention,  accompanied 
by  complete  general  amnesia  does  not  quite  accord  with 
this  diagnosis. 

As  it  transpired  at  the  post-mortem  examination, 
the  patient  had  a  sarcoma  in  his  right  cerebral  hemisphere. 

Prognosis 

The  outlook  in  cases  of  cerebral  tumours,  etc.,  is  dis- 
cussed in  textbooks  of  medicine.  The  excitement  in 
many  cases  only  terminates  with  the  onset  of  the  coma 
that  precedes  death.     A  few  cases  exhibit  remissions. 

Diagnosis 

The  general  method  of  diagnosis  is  indicated  on  the  pre- 
ceding pages,  but  the  importance  of  a  very  thorough 
physical  examination  should  be  emphasized.  The  exist- 
ence of  combined  psychoses  (the  most  difficult  question 
in  clinical  psychiatry)  should  be  always  borne  in  mind. 


46  COMMON  TYPES  OF  INSANITY 

Apart  from  physical  indications,  these  cases  are  often 
only  elucidated  by  their  course  and  results. 

Treatment 

The  management  of  the  excitement  is  identical  with 
that  suggested  for  acute  confusional  insanity. 


9.  STATES  OF  EXCITEMENT  IN  SENILE  DEMENTIA 

For  convenience,  and  owing  to  the  relative  frequency 
with  which  they  are  found  as  separate  entities,  three  clinical 
forms  of  excitement  occurring  in  senile  dementia  may  be 
described,  but  naturally,  they  merge  into  each  other. 

1.  Maniacal  excitement. 

2.  Confusional  episodes. 

3.  Conditions  resembling  G.P.I. 

1.  The  first  condition  is  clinically  mania  plus  senile 
mental  impairment.  Whether  it  is  an  expression  of  the 
manic-depressive  diathesis,  is  due  to  abiotrophic  and 
arteriopathic  changes,  or  both,  is  doubtful.  It  is  dis- 
tinguished from  mania  occurring  in  normal,  i.e.,  unde- 
teriorated  old  persons,  by  the  presence  of  the  demential 
symptoms  (vide  dementia  senilis,  p.   102). 

2.  Amential  episodes  must  be  regarded  setiologically 
as  intoxication  incidents  occurring  in  the  course  of  senile 
dementia. 

In  practice  they  have  to  be  separated  from  amentia 
in  sane  old  people.  In  the  case  of  the  dement  the  episodes 
show  less  agitation,  apprehension,  rapidity  of  mental 
action  and  fewer  changes  of  mood,  than  uncomplicated 
amentia.  Hallucinations  are  more  sparse  and  may  be 
absent.  The  patients  are  more  accessible,  and  then, 
divertible.  There  may  be  no  very  definite  emotional 
tone.     The  lucid  intervals   demonstrate  the   dementia, 


EXCITEMENT  DUE  TO  DRUGS  47 

As  noted  under  the  last  section  (Case  III)  amential 
episodes  in  arteriopathic  and  abiotrophic  cases  may 
resemble  other  organic  brain  lesions.  The  attacks  are 
usually  of  only  a  few  days'  duration. 

3.  This  form  is  characterized  by  marked  dementia, 
and  amnesia,  euphoria,  absurd  grandiose  delusions,  and 
motor  restlessness. 

It  differs  from  G.P.I.  chiefly  in  the  following  features  : 
(a)  The  age  of  the  patient. 

(6)  The  presence  of  a  degree  of  dementia  only 
compatible  in  G.P.I,  with  advanced  physical 
signs  and  cachexia, 
(c)  The  lively  emotional  state,  more  active  and 
quicker  mentation,  and  better  passive  atten- 
tion. 

Treatment  of  Senile  Excitement 

Apart  from  tube  feeding,  which  is  practically  never 
required  in  these  cases,  the  treatment  is  the  same  as 
that  recommended  for  amentia.  Owing  to  the  feebleness 
of  the  patients  and  their  frequent  habit  of  crawling  about, 
padded  floors  are  desirable  in  their  single  rooms.  If  these 
are  not  available  mattresses  should  be  placed  on  the  floor 
to  cover  it  completely. 


10.  STATES  OF  EXCITEMENT  DUE  TO  DRUGS 

Certain  poisons  produce  delirious  states  (resembling 
amentia)  in  one  of  two  ways  ;  either  as  the  result  of 
acute  poisoning  or  as  an  abstinence  symptom.  Ex- 
amples of  drugs  of  the  former  class  are  Cannabis  indica  and 
belladonna,  and  the  delirium  is  distinguished  by  the  physi- 
cal signs  produced  by  the  poison  from  which  it  arises.  The 
commonest  toxins  producing  acute  confusion  as  the  result 


48  COMMON  TYPES   OF  INSANITY 

of  abstinence  are  as  follows  :  alcohol  (already  discussed), 
morphia,  cocaine,  chloral.  In  the  last  three,  the  physical 
signs  present  in  the  delirium  are  such  as  would  be  pro- 
duced by  a  perfect  antidote  to  the  respective  drugs. 
In  fact,  the  condition  is  regarded  as  due  to  an  excess  of 
anti-bodies  in  the  blood. 

Morphinism  not  infrequently  produces  a  more  or  less 
lucid  delirium  with  marked  visual  hallucinations  and 
systematized  delusions  of  persecution,  accompanied  by 
irritable,  aggressive,  or  dangerous  mood. 

For  the  physical  signs  of  poisonings  and  their  medical 
treatment  other  works  must  be  consulted.  The  manage- 
ment of  the  excitement  is  similar  to  that  of  amentia. 

Few  cases  are  admitted  without  a  clear  history  of 
drug  habit.  The  frequency  of  the  co-existence  of  mor- 
phinism, cocainism,  and  alcoholism  should  be  borne  in 
mind/ 


CHAPTER  II 
STATES  OF  DEPRESSION 

1.  MELANCHOLIA 

Melancholia  is  more  or  less  widely  considered  as  a  phase 
of  manic  depressive  insanity.  It  may  recur  as  such,  may 
alternate  with  mania,  with  or  without  normal  periods 
between,  or  be  combined  with  it ;  and  finally,  melan- 
cholia quite  commonly  occurs  as  an  isolated  attack  once 
in  a  lifetime.  A  priori,  one  would  presume  the  absence 
of  any  particular  diathesis  or  temperament  in  the  case  of 
single  attacks,  and  this  is  borne  out  by  previous  know- 
ledge of  the  patient  and  by  the  existence  of  conspicuous 
external  cause. 

Definite  exciting  causes  are  more  common  in  the  case 
of  melancholia  than  mania,  and  the  duration  of  the  attack 
is  usually  longer.  The  essential  feature  of  melancholia 
is  misery  from  inadequate  existing  external  causes.  The 
depth  of  the  unhappiness  varies  in  different  cases,  from 
simple  depression  of  spirits  to  shrieking  anguish. 

In  some  cases  the  disease  becomes  chronic,  and  in  these 
the  power  of  feeling  grows  so  blunted  that  scarcely  any 
emotion  at  all  is  experienced.  Such  patients  often  retain 
some  special  unpleasant  delusion  which  they  cherish, 
and  apparently  almost  take  a  pleasure  in. 

Melancholies  are  so  absorbed  by  their  mental  pain 

E.M.D,  49  i 


50  COMMON  TYPES  OF  INSANITY 

that  they  are  impervious  to  pleasant  sensations  or 
thoughts,  and  often  to  real  external  causes  of  distress. 
They  are  lucid,  well  orientated,  have  good  comprehension 
and  memory.  There  is  one  exception  to  this  rule  ;  some 
cases  suffer  from  very  vivid  irrepressible  ideas  and  im- 
pulses (e.g.,  to  suicide,  mutilation)  which  may  at  times 
result  in  sudden  violent  action.  In  this  state  (termed 
raptus)  the  patient  is  so  engrossed  in  his  idea  that  he  is 
practically  unconscious  of  all  else. 

Apart  from  raptus,  clouding  of  consciousness  occurring 
in  melancholia  must  be  regarded  as  an  exhaustion  (i.e., 
intoxication)  symptom  ;  so  also  must  any  degree  of  con- 
fusion, or  hallucinations.  These  symptoms  do  not  occur 
in  uncomplicated  melancholia. 

Another  important  feature  of  melancholia  is  paresis 
or  impediment  of  volition.  This  is  always  present  during 
some  part  of  the  attack,  and  often  throughout  the  course 
until  the  patient  begins  to  recover.  The  result  is  in- 
decision, difficulty  in  doing  anything,  slow  action,  speech, 
and  re- action  to  stimuli  ;  the  patient  having  to  make 
an  obvious  effort  to  overcome  the  obstruction.  In  some 
cases,  this  impediment  of  will  produces  definite  stupor 
(vide  Stupors,  p.  86). 

Many  melancholies  develop  delusions,  unpleasant  or 
fearful,  and  always  self-depreciatory.  These  erroneous 
ideas  are  never  intrinsically  impossible,  but  often  outside 
the  bounds  of  possibility  under  the  existing  circumstances. 
Various  absurdities  are  described  by  patients  as  seeming 
so,  but  they  know  such  are  not  really  the  case. 

The  commonest  delusions  are  of  sin,  ruin,  damnation, 
injury  to  relatives,  present  illness,  and  impending  death. 
Insomnia  is  constant  in  acute  melancholia,  and  constipa- 
tion the  rule. 

Some  melancholies,  especially  senile  cases,  appear  more 
irritable  than  obviously  unhappy.    Many  are  resistive 


MELANCHOLIA  51 

to  all  interference.  This  obstinacy  must  not  be  confused 
with  true  negativism  (vide  Glossary),  which  does  not 
occur  in  melancholia.  Persons  suffering  physical  pain 
frequently  resent  any  interference,  a  fortiori,  those  suffer- 
ing mental  pain.  The  resistance  in  its  conception  is 
logical. 

The  symptoms  of  melancholia  then  may  be  briefly 
summarized  as  follows  : — 

1.  Genuine  misery,  without  adequate  external  cause. 

2.  Self- depreciation. 

3.  Slow  painful  ideation,  often  concerned  with  some 
special  train  of  thought,  from  which  the  mind  can  only 
be  transitorily  diverted. 

4.  Impediment  of  will. 

5.  Delusions,  if  present,  depressing,  self-depreciatory, 
unchangeable  by  argument,  and  within  the  bounds  of 
possibility. 

6.  Collectedness  and  good  memory. 

7.  Reasonable  conduct,  the  logical  outcome  of  the 
thoughts  and  feelings  (due  allowance  being  made  for 
volitional  paresis). 

8.  Insomnia,  in  recent  cases. 


Prognosis 

The  outlook  in  a  recent  case  of  melancholia  is  good. 
About  half  of  these  patients  recover  completely,  and  a 
fair  proportion  of  the  remainder,  though  slightly  impaired 
in  mental  action  and  emotional  sensibility,  get  well  enough 
to  return  home. 

Cases  under  middle  age  are  more  likely  to  recover, 
but  more  prone  to  recur.  Very  short  attacks  also  tend 
to  recur.  A  duration  of  three  years  is  not  incompatible 
with  ultimate  recovery. 


52  COMMON  TYPES  OF  INSANITY 

Treatment 

In  acute  cases  more  or  less  marked  debility  accompanies 
the  depression.     These  patients  must  be  kept  in  bed. 

When  the  case  is  admitted,  it  is  well  to  give  enemata 
until  the  bowels  act,  and  then  a  calomel  purge.  After- 
wards, the  patient  should  be  kept  on  some  aperient  mixture 
regularly.  The  diet  at  first  should  be  light  and  fattening, 
e.g.,  milk,  eggs,  meat  juices,  etc. 

As  the  acute  stage  passes  off,  the  patient  must  be  fed 
more  liberally  until  he  is  on  full  diet  in  addition  to  milk 
and  other  extras.  As  all  melancholies  are  potential 
suicides,  only  spoons  should  be  allowed  them  until  their 
individual  tendencies  are  known.  A  certain  proportion 
of  melancholies  refuse  food.  They  can,  however,  often 
be  induced  to  eat  by  firm  persuasion  or  spoon-feeding  by 
an  attendant.  Others  have  to  be  fed  by  the  stomach 
tube,  but  there  is  not  the  urgency  for  its  use  that  exists 
in  the  case  of  amentia. 

The  drugs  most  useful  in  the  treatment  of  melancholia 
are  opium,  paraldehyde,  and  in  cases  with  high  blood- 
pressure,  nitrites.  Tr.  Opii  Ms.  x  to  xxx  combined  with 
Mag.  Sulph.  and  Nux  Vomica,  has  sometimes  proved 
valuable. 

For  insomnia  a  drachm  or  two  of  paraldehyde  can  be 
given  in  addition.  Intestinal  antiseptics  are  recommended, 
but  the  writer  has  seen  no  better  results  from  these  than 
from  simple  purgation.  Calomel  in  small  doses,  e.g. 
\  gr.  t.d.s.,  serves  both  purposes. 

After  the  subsidence  of  the  acute  stage,  tonics  such 
as  Easton's  Syrup  may  be  given  ;  the  casein  and  glycero- 
phosphate foods  are  useful  from  the  beginning. 

Sour  milk  preparations  can  at  least  do  no  harm,  pro- 
vided the  bowels  are  kept  active,  and  they  make  a  change 
for  the  patient. 


MELANCHOLIA  53 

Cases  of  prolonged  raptus  and  those  with  exhaustion 
symptoms  must  be  treated  as  amentia. 

Owing  to  the  impediment  of  will  beginning  later  and 
disappearing  before  the  depression  of  spirits,  melancholies 
are  more  prone  to  commit  suicide  at  the  beginning  and  at 
the  end  of  their  attack  ;  so  early  discharge  from  the 
asylum,  or  the  cessation  of  careful  observation  at  home, 
should  be  discountenanced. 


Differential  Diagnosis 

Of  the  preceding  conditions  amentia  is  the  only  one 
with  which  melancholia  as  described  here  can  be  con- 
fused. 

In  ordinary  severe  forms  of  agitated  melancholia,  the 
absence  of  hallucinations,  imperception,  flight  of  ideas, 
disorientation,  etc.,  distinguish  it  at  once  from  amentia 
agitata.  In  melancholia  with  exhaustion  (i.e.,  intoxica- 
tion symptoms)  the  diagnosis  is  not  so  obvious.  The 
difference  lies  mainly  in  the  melancholic 's  continuous 
mood  of  depression,  his  much  less  rapid  ideation,  and  the 
slighter  degree  of  clouding  of  consciousness.  Many  of 
these  latter  cases  are  stuporose  and  resemble  amentia 
attonita  (vide  Stupors,  p.   89). 

In  severe  cases  of  raptus,  melancholies  may  shriek, 
lacerate  themselves,  pull  out  their  hair,  etc.,  continuously 
for  weeks,  and  are  apparently  unconscious  of  their  sur- 
roundings. Some  also  exhibit  hallucinations  (exhaus- 
tion). Here  again,  the  unchanging  mood,  and  the  absence 
of  flight  of  ideas,  are  the  chief  distinctions  from  amentia  ; 
moreover,  most  of  these  patients  can  by  insistence  be 
made  to  reply  sensibly,  if  briefly,  to  a  question,  although 
they  return  at  once  to  their  self-engrossed  state  of  misery  ; 
thus  showing  that  their  consciousness  is  not  so  clouded  as 
it  appears. 


84  COMMON  TYPES  OF  INSANITY 

2.  STATES  OF  DEPRESSION  IN  DEMENTIA 
PRECOX 

A  period  of  depression  resembling  melancholia  fre- 
quently occurs  at  the  onset  of  dementia  prsecox,  and 
short,  less  accentuated  attacks,  are  often  scattered 
throughout  the  earlier  part  of  its  course.  The  latter 
usually  take  the  form  of  transitory  bouts  of  weeping,  etc., 
of  no  clinical  significance. 

Symptoms 

The  following  are  the  chief  features  of  the  well  marked 
attacks  of  depression  : — 

1.  Misery  that  is  more  apparent  than  real,  either  with 
some  motor  unrest  or  of  quiet  variety,  more  frequently 
the  latter.  The  apparent  insincerity  of  the  unhappiness 
is  due  to  the  fundamental  emotional  dullness  of  dementia 
prsecox.  This  is  shown  by  a  certain  theatrical  display  oi 
misery,  by  exaggerated  expression,  and  occasional  vacant 
smile  or  laugh,  or  by  a  temporary  spell  of  cheerfulness, 

2.  Seclusiveness  often,  in  quiet  types. 

3.  Hallucinations  commonly,  especially  of  hearing. 

4.  Absence  of  desire  for  action,  not  always  easily  dis- 
tinguished from  the  melancholic 's  impediment  of  will, 
the  results  being  much  the  same. 

5.  Some  indications  of  katatonia.  These  are  not  by 
any  means  constant,  but  illogical  conduct,  purposeless 
movements  and  gesticulations,  affected  mannerisms, 
negativism,  may  be  noted  at  intervals  in  some  cases. 
Abnormalities  of  speech  are  commoner,  e.  g.  occasional 
irrelevant  meaningless  or  silly  remarks,  more  rarely 
echolalia,  verbigeration  or  neologisms  are  encountered 
(vide  Glossary). 

Some  cases  rapidly  develop  katatonic  stupor  (q.v.). 


DEPRESSION   IN   DEMENTIA   PRECOX      55 

<3.  Delusions  are  generally  present,  often  persecutory, 
hypochondriacal,  or  intrinsically  absurd. 

7.  Collectedness  and  good  memory. 

8.  The  "  self -puzzled "  state  common  in  all  early 
manifestations  of  dementia  prsecox  (vide  p.  90). 

Differential  Diagnosis 

In  the  majority  of  cases  some  of  the  special  dementia 
praecox  symptoms  mentioned  above,  will  at  once  distin- 
guish depression  in  that  affection  from  melancholia.  In 
those  in  which  these  signs  do  not  at  once  display  them- 
selves, the  insincerity  of  the  woe  usually  elucidates  the 
diagnosis.  Moreover,  impediment  of  will  and  sincere 
self- depreciation  are  absent  in  dementia  prsecox. 

It  must  be  confessed  however,  that  in  practice  some  of 
the  initial  cases  of  depression  are  exceedingly  difficult 
to  distinguish  from  melancholia. 

Prognosis 

A  small  minority  of  cases  apparently  recover,  and  of 
these  some  become  insane  again,  and  finally  demented. 
A  few  others  remain  seclusive  and  apathetic,  but  are  fit 
to  be  at  large.  About  80  per  cent,  grow  progressively 
demented.  Cases  without  katatonia  are  of  most  favour- 
able prognosis. 

Treatment 

This  is  on  the  same  fines  as  for  melancholia.  These 
cases  often  possess  strong  tendencies  to  suicide,  in  order 
to  escape  from  persecution,  or  in  response  to  "  voices." 
As  they  suffer  from  no  impediment  of  will,  their  attempts 
are  often  sudden,  thorough  and  determined,  and  inci- 
dentally bizarre. 


56  COMMON  TYPES  OF  INSANITY 

3.  STATES    OF   DEPRESSION   IN    GENERAL 
PARALYSIS 

A  state  of  depression  may  usher  in  G.P.I,  and  persist 
more  or  less  throughout  its  course,  or  give  place  after  a 
short  time  to  other  phases  of  the  disease. 

The  melancholic  condition  may  be  of  a  quiet  dull 
variety  or  be  accompanied  by  motor  unrest  and  noisy 
lamentations. 

Differential  Diagnosis 

(A)  From  Melancholia  : 

1.  The  following  features  are  present  in  G.P.I.,  but 
absent  in  melancholia  : 

(a)  Distress  that  is  shallow  and  superficial  owing  to 

the  all  round  dulling  of  the  faculties,  both 
emotional  and  intellectual,  characteristic  of 
G.P.I. 

(b)  Evidence  of  exaltation  of  the  ego  ;    in  speech, 

conduct,  etc. 

(c)  Delusions  (often  intrinsically   impossible)  mani- 

festing the  same,  e.  g.,  persecutions  by  great 
persons,  or  by  large  numbers  of  people.  Hy- 
pochondriacal ideas  often  show  a  similar  under- 
current, e.  g.,  that  the  bowels  are  blocked  by 
gold. 

(d)  Flashes   of  euphoria   and  temporary  grandiose 

ideas,  generally  at  night,  are  not  uncommonly 
seen. 

(e)  Occasional    attacks  of  confusion  (not  very  fre- 

quent in  this  phase  of  G.P.I.) 
(/)  Some  degree  of  intellectual  deterioration,  e.  g., 
impaired  memory,   attention,    perception,   and 
inability  to  do  simple  sums. 


DEPRESSION  IN  GENERAL  PARALYSIS      57 

(g)  Volitional  feebleness  and  divertibility.  One  may 
sometimes  make  a  paralytic  who  thinks  he  is 
dying  and  eternally  damned,  smile  or  laugh 
and  talk  of  other  matters. 

(h)  Physical  signs  of  G.P.I. 

2.  In  G.P.I,  the  following  do  not  occur  : 

(a)  Deep  misery. 

(b)  Self- depreciation  and  altruistic  despair. 

(c)  Impediment  of  will. 

(d)  Insight  into  personal  condition ;     often  present 

in  melancholia. 

(B)  Feom  Depression  in  Dementia  Praecox  : 

There  is  in  some  of  the  later  forms  of  the  above  disease 
no  little  resemblance  to  G.P.I.  Stress  should  be  laid  on 
the  following  points  : 

1.  Present  in  G.P.I.  : 

(a)  Shallow,  but  sincere  depression. 

(b)  Defects    of    memory,    perception    and   passive 

attention. 

(c)  Volitional  feebleness  and  divertibility. 

(d)  Transitory  euphoria  and  expansive  delusions. 

(e)  Physical  signs. 

2.  Absent  in  paralytic  depression  : 

(a)  Pedantry  and  affectation. 

(&)  Katatonia,  including  negativism. 

(c)  Meaningless  remarks,  echolalia,  neologisms. 

(d)  Purposeless    conduct    (apart    from    confusional 

episodes). 

(e)  Hallucinations    of    hearing    and    sight,    in    the 

majority  of  cases. 


58  COMMON  TYPES   OF  INSANITY 

4.  THE    DEPRESSION    OF    INVOLUTION    AND 
SENILITY 

Three  main  clinical  types  of  depression  present  them- 
selves at  the  onset,  or  during  the  progress  of  involution. 
Perhaps  their  chief  interest  lies  in  the  aetiology,  a  dis- 
cussion concerning  which  cannot  be  entered  upon 
here. 

1.  The  first  variety  is  indistinguishable  from  melan- 
cholia, and  should  possibly  be  regarded  as  an  expression 
of  the  manic-depressive  diathesis.  A  history  of  former 
phases  is  sometimes  forthcoming. 

2.  True  involutional  depression  (that  to  which  Krsepelin 
has  arbitrarily  restricted  the  term  melancholia)  charac- 
terized by  restless  misery  of  a  lucid  type,  manifesting  no 
impediment  of  will,  slowing  of  ideation,  or  mental  de- 
terioration. 

It  usually  occurs  at  the  onset  of  involution,  and  is 
possibly  merely  an  exaggeration  of  the  physiological 
depression  of  that  period,  analogous  to  the  exaggeration 
of  the  normal  Men  d'etre  of  puberty  that  sometimes 
occurs. 

Delusions,  however,  may  be  present,  though  these  are 
generally  more  of  the  nature  of  magnifications  of  actual 
causes  of  unhappiness,  than  baseless  erroneous  ideas. 

In  these  cases,  there  is  no  history  of  previous  attack. 

3.  Senile  depression  occurs  later  physiologically.  It 
differs  from   melancholia  in  the  following   respects  : — 

(1)  In  the  presence  of  symptoms  due  to  the  egotism  of 
old  age,  viz.  : 

(a)  Absence  of  deep  self -depreciation. 
(&)  Absence  of  altruistic  depression, 
(c)  Frequency  of  delusions  of  apprehensive  nature, 
of  personal  injury  and  persecution,   or  hypo- 
chrondriacal  notions. 


DEPRESSION  OF  INVOLUTION  59 

(2)  In  the  presence  of  signs  of  intellectual  impairment : 

(a)  Feeble  volition  and  divertibility. 

(b)  Loss  of  power  to  retain  recent  impressions  and 

other  mnemonic  defects  (vide  Dementia  senilis, 
p.    102). 

(c)  The  occurrence  in  some  cases  of  short  periods  of 

exaltation  or  confusion. 
Impediment  of  will  is  absent  in  these  cases. 
They  should  probably  be  regarded  as  a  depressed  phase 
of  senile  dementia. 

Treatment 

The  treatment  of  these  depressed  states  occurring 
in  the  involutionary  period  does  not  differ  from  that  of 
melancholia,  except  that  allowance  must  be  made  on 
medical  grounds  for  the  age  of  the  patient,  e.  g.,  in  the 
administration  of  sedatives. 

Prognosis 

1.  Melancholia  at  this  period  of  life  lasts  longer  than 
in  younger  folks,  and  some  emotional  dulling  commonly 
remains. 

2.  Krsepelin's  melancholia  runs  much  the  same  course 
as  other  melancholic  attacks,  and  recovery  is  equally 
probable. 

3.  Senile  depression  terminates  in  dementia  of  senile 
type.  The  depression  usually  passes  off  as  the  dementia 
progresses. 

5.  EPILEPTIC  DEPRESSION 

Depression  in  epileptics  is  an  equivalent  (an  incident 
analogous  to  a  fit)  and  hence  such  attacks  are  more  or 
less  periodical,  frequent,  sudden,  short  (not  more  than  a 


60  COMMON  TYPES  OF  INSANITY 

day  or  two),  similar,  and  without  external  cause.  It 
sometimes  precedes  or  follows  convulsions,  more  fre- 
quently the  former. 

The  depression  is  of  a  quiet  nature,  not  as  a  rule  accom- 
panied by  definite  delusions,  but  often  by  somatic  sensa- 
tions and  ideas  of  bodily  illness,  or  by  fancies  of  persecu- 
tion, insult,  or  neglect,  based  upon  misconstruction  of 
the  conduct  of  others. 

The  usual  epileptic  "  wound  up  "  temper  and  irrita- 
bility are  present,  and  sometimes  a  slight  degree  of 
confusion.  The  egotistical  self-esteem,  sensitiveness,  slow 
clumsy  mentation,  and  external  religiosity  of  the  chronic 
epileptic  in  all  his  phases,  will  also  be  apparent. 

The  above  points  are  amply  sufficient  to  distinguish 
this  form  of  depression  from  every  other.  It  will  be 
observed  that  it  borders  upon  epileptic  confusion,  and 
of  course  the  distinction  is  arbitrary, — only  a  matter  of 
the  relative  prominence  of  the  respective  denominating 
symptoms. 

Treatment 

No  treatment  is  required,  except  an  aperient.  Tact  and 
sympathy,  together  with  the  assurance  that  the 
(imaginary)  ailment  will  be  watched  by  the  doctor,  and 
treated,  if  necessary,  and  the  (imaginary)  grievances 
investigated — which  by  the  way,  should  be  done — are 
all  that  is  necessary.  In  some  cases,  where  one  has  gained 
the  patient's  confidence,  one  can  explain  to  him  with 
benefit  that  his  morbid  feelings  are  substituted  for  a  fit 
and  that  nothing  else  is  really  amiss. 


CHAPTER  III 
DELUSIONAL  STATES 

1.  PARANOIA 

Paranoia  is  a  delusional  condition,  sometimes  regarded 
as  an  atavistic  anomaly.  It  is  of  gradual  development 
and  exerts  no  influence  upon  the  bodily  health.  There 
is  reason  for  thinking  that  at  bottom  it  is  a  disorder  or  per- 
version of  instincts  common  to  all  men  ;  i.  e.,  of  the 
subconscious  ego.  The  psycho-analysts  regard  it  of  course 
as  of  sexual  origin  and  attribute  it  to  repressed  homo- 
sexuality. 

The  development  of  delusions  in  persons  of  paranoical 
temperament  is  an  extremely  likely,  but  not  necessary 
contingency.  Some  cases  never  develop  delusions  at  all, 
others  need  the  aid  of  a  psychosis,  or  stress  of  circum- 
stances to  bring  the  development  to  pass.  The  conduct 
of  delusional  paranoiacs  usually  brings  them  into  conflict 
with  their  environment  between  the  ages  of  40  and  60. 
It  is  then  necessary  to  confine  them  in  some  sort  of  institu- 
tion. The  mental  family  history  of  paranoiacs  is  almost 
invariably  bad. 

When  the  delusions  are  fully  matured  paranoiacs 
present  the  following  characters  : — 

1.  A  coherent  delusional  view  of  life  into  which  all 
events  are  fitted  by  a  process  of  misinterpretation  and 
illusion,  and  past  incidents  dovetailed  by  means  of  pseudo- 
reminiscence  (imaginary  memory).     The  ever  widening 

61 


62  COMMON  TYPES  OF  INSANITY 

edifice  of  this  delusionary  structure  is  built  up  upon  the 
false  basis  of  an  inherent  pre-conception,  and  is  permanent, 
fixed   and    unalterable    by    argument.    The    delusional 
content  may  be  : — 
.  (a)  Abstract  and  apparently  altruistic,  e.  g.,  propaganda 
of    impracticable    schemes    and    theories.     Such 
paranoiacs  are  called  "  Mattoids." 
(6)  Ego-centric  : 

(i)  Persecutory,     (ii)  Ambitious,     (iii)   Querulant 
(persecuted  persecutors),    (iv)  Erotic,    (v)  Hypo- 
chondriacal. 
In  many  cases  these  varieties  tend  to  merge  into  each 
other  as  years  go  on,  and  they  are  all  present  in  embryo 
in  all  paranoiacs.     The  delusions  are  never  intrinsically 
impossible  under  every  conceivable  combination  of  cir- 
cumstances. 

2.  A  normal  emotional  state  and  reaction,  except  for 
exaggerated  self-esteem  and  "  touchiness." 

3.  Logical  conduct,  and  dignified  bearing. 

4.  Lucid  unimpaired,  often  powerful  intelligence  and 
memory,  except  for  the  warped  judgment  and  pseudo- 
reminiscence  in  connexion  with  the  delusions.  Active 
mentation,   untiring  energy  and  power   of  application. 

5.  Strong  volition  and  absolute  undivertibility. 

6.  Very  occasional  hallucinations.  Some  ambitious 
paranoiacs  under  great  stress  of  emotion  enjoy  (used 
advisedly)  hallucinations,  just  as  hysterical  individuals 
may. 

A  few  deliberately  invent  them,  but  afterwards  come 
to  believe  their  own  fabrications. 

Prognosis 

Paranoiacs  cannot  lose  their  delusionary  outlook  upon 
life,  any  more  than  normal  persons  can  change  their 


PERSECUTORY  HYPOCHONDRIA  63 

temperaments.  For  it  is  the  temperament  that  is  essen- 
tial to  the  development  of  the  delusions  of  paranoia. 

A  few  cases,  however,  decide  not  to  allow  their  views 
to  exercise  much  influence  upon  their  conduct ;  especially 
when  they  find  such  self-denial  saves  them  from  an  asylum. 

There  is  no  tendency  to  dementia,  but  persons  of 
paranoical  temperament  are  susceptible  to  attacks  of 
psychoses. 

Treatment 

There  is  of  course  none.  Those  persons  who  are  a 
danger  or  a  nuisance  to  other  people  must  be  confined 
somewhere,  and  an  asylum,  though  essentially  unsuitable, 
seems  to  be  the  only  place  available. 

In  dealing  with  paranoiacs,  it  is  useless  pretending  to 
them  that  they  are  ill ;  they  are  only  irritated  thereby. 
They  should  be  treated  on  a  footing  of  polite  equality, 
and  persuaded  to  occupy  themselves  usefully  in  the  asy- 
lum.    It  is  better  to  ignore  their  delusions. 

Their  conduct  is  usually  exemplary,  but  if  they  are  a 
source  of  annoyance  to  other  patients,  it  should  be  quietly 
explained  to  them  that  their  ideas  are  their  own  ("  we 
must  agree  to  differ  "),  but  they  must  not  do  anything  to 
disturb  the  harmonious  working  of  the  asylum.  They 
usually  see  the  force  of  such  arguments. 

Some  further  notes  on  the  paranoical  temperament  will 
be  found  under  the  heading  of  Border-line  cases  (p.  123). 

2.  PERSECUTORY  HYPOCHONDRIA 

An  affection  of  delusional  nature  occurring  at  about 
the  menopause  in  women  and  at  an  analogous  period  of 
life  in  men.  The  condition  is  usually  described  as  one  of 
the  varieties  of  dementia  prsecox.     (What  is  not  ?) 

It  is  treated  here  as  a  separate  condition,  for  reasons 
that  will  appear  from  the  subjoined  symptoms,  course, 


64  COMMON  TYPES   OF  INSANITY 

and  termination.  It  should  be  borne  in  mind,  however, 
that  some  paranoid  forms  of  dementia  prsecox  in  the  early 
stages,  manifest  delusions  similar  in  content.  Persecu- 
tory Hypochondria  should  probably  be  regarded  as  an 
involution  delusional  insanity,  and  possibly  its  resem- 
blances to  dementia  prsecox — the  developmental  in- 
sanity par  excellence — are  due  to  the  existence  of  some 
disorder  of  sexual  metabolism  in  both. 

The  distinctions  from  dementia  paranoides,  i.e.,  the 
paranoid  forms  of  dementia  prsecox  (vide  p.  66),  are  as 
follows  : — 

1.  Persecutory  hypochondria  as  described  here  does 
not  present  the  fundamental  feature  of  dementia  prsecox, 
viz. — "  Failure  of  every  impulse  to  energy.  Loss  of 
mental  activity  and  interest  in  particular,  emotional 
dullness  and  absence  of  independent  impulses  of  will." 
(Krcepelin.)  "  Affective  vacuity,  stolidity  of  conduct. 
The  will  does  not  act  under  the  influence  of  motives, 
but  from  organic  stimuli,  which  have  no  psychical 
correlative."     (Tanzi.) 

2.  It  does  not  terminate  in  incoherent  dementia. 

3.  Katatonia,  negativism,  "  mannerisms,"  automatic 
obedience,  purposeless  acts,  illogical  conduct,  moral 
degradation,  and  the  abnormalities  of  speech — character- 
istic of  dementia  prsecox, — form  no  part  of  its  symptom- 
atology. 

4.  The  type  of  delusion  remains  unalterable  and  fixed, 
viz  :  bodily  molestation,  and  the  individual  content  fairly 
coherent  and  simple  to  the  end. 

5.  The  onset  occurs  after  the  age  of  forty. 

Symptoms  of  Persecutory  Hypochondria 

1.  Unshakeable  delusions  of  persecution  of  the  nature 
of  physical  injury  or  interference  by  some  unseen  agencies 


PERSECUTORY  HYPOCHONDRIA  65 

or  persons,  e.  g.,  by  electricity,  hydraulic  power,  etc., 
and  these  attacks  may  be  attributed  by  the  patient  to 
definite  living  people. 

The  exact  description  of  the  persecution  given  by  the 
patient  is  probably  governed  by  hallucinations,  and  may 
vary  from  time  to  time,  but  the  type  remains  un- 
changed. 

2.  Hallucinations,  especially  of  hearing  (voices,  etc.) 
and  of  bodily  sensation. 

3.  A  mood  of  excitability  and  resentment  against  per- 
secution, developing  at  times  into  definite  depression 
or  angry  excitement.  These  emotional  disturbances 
are  sincere,  and  do  not  display  the  impress  of  basic 
apathy. 

4.  Collectedness  and  rationality  apart  from  the  delu- 
sions, with  active  mentation  and  good  memory. 

5.  Normal  speech,  except  for  occasional  neologisms 
(such  as  occur  even  in  paranoia)  to  explain  the  mode  of 
persecution. 

6.  Logical  and  decent  conduct. 

7.  Remissions,  during  which  there  is  freedom  from 
hallucinations,  almost  normal  emotional  tone  and  con- 
duct, and  as  far  as  can  be  ascertained,  absence  of  delusion. 
Many  patients,  if  not  all,  at  such  times  enjoy  an  insight 
into  their  past  condition  and  recognize  that  the  hallucina- 
tions and  delusions  were  of  morbid  origin.  These  re- 
missions may  endure  for  several  weeks,  or  even  longer. 

8.  A  definite  onset  which  may  be  more  or  less  abrupt 
and  coloured  by  excitement,  depression  or  confusion. 

Prognosis 

The  ultimate  prognosis  is  hopeless.  These  patients, 
apart  from  remissions,  remain  unchanged  for  years,  and 
finally  become  weak-minded  and  senile. 

e.m.d.  5 


66  COMMON  TYPES  OF  INSANITY 

Treatment 

There  is  at  present  no  known  treatment  of  any  avail. 
Suicidal  and  violent  tendencies  are  not  uncommon,  al- 
though in  asylums  the  patients  for  the  most  part  behave 
well  and  make  useful  workers,  except  when  upset  too  much 
by  their  hallucinations. 

Differential  Diagnosis 

The  main  points  to  bear  in  mind  in  distinguishing  this 
condition  from  paranoia,  are  as  follows  : — 

1.  The  absence  in  persecutory  hypochondria  of  the 
systematized  delusionary  view  of  life,  resulting  from  the 
piecing  together  of  disconnected  incidents  spread  over 
years. 

2.  The  absence  in  paranoia  of  chronic  hallucinations. 

3.  The  existence  of  an  onset  and  the  occurrence  of 
remissions  in  persecutory  hypochondria. 

3.  DEMENTIA  PARANOIDES 

The  varieties  of  dementia  praecox,  namely  hebephrenia, 
katatonia,  and  the  paranoid  form  now  to  be  considered, 
merge  into  each  other  and  rarely  occur  pure.  The  para- 
noid form  is  merely  characterized  by  the  prominence  of 
delusions,  in  some  cases  by  a  more  chronic  course,  and 
usually  a  later  onset. 

Symptoms 

The  main  features  of  a  typical  case  are  as  follows  : — 

1.  Delusions — fantastic,    absurd,    ever   changing,  and 

increasing  in  number.     They  are  apt  to  be  persecutory 

at  first  (e.  g.,  unseen  influences,  mesmerism,  injury  by 

hidden  machines,  reading  of  the  patient's  thoughts,  etc,) 


DEMENTIA  PARANOIDES  67 

and  grandiose  later.  This  is  the  usual  tendency  of  delu- 
sions accompanied  by  progressive  dementia,  as  these  are  : 
only  in  the  early  persecuted  stages  do  the  delusions  affect 
the  conduct  to  any  great  extent. 

2.  Chronic  hallucinations,  chiefly  "  voices." 
Pseudo-hallucinations   (vide  Glossary)  are  peculiar  to 

dementia  prsecox,  and  this  one  symptom  when  present 
with  delusions  is  sufficient  to  enable  one  to  make  a 
diagnosis  of  that  affection. 

3.  The  basic  apathy,  emotional  dullness,  and  absence 
of  interest — of  dementia  prsecox. 

4.  Some  degree  of  katatonia  or  catalepsy,  e.  g.,  nega- 
tivism, automatic  obedience,  mannerisms,  etc. — not 
common  in  early  stages. 

5.  Motiveless  conduct  (this  statement  does  not,  of 
course,  mean  that  every  action  of  the  precocious  dement 
is  motiveless). 

6.  Pedantic,  affected,  stereotyped  or  occasional  mean- 
ingless speech. 

7.  Good  memory,  comprehension  and  orientation. 

8.  Onset,  often  with  an  attack  of  depression,  excite- 
ment, or  confusion. 

9.  Termination  in  incoherent  dementia,  within  six 
months  to  five  years  of  the  onset. 

Prognosis 

None  of  these  cases  recover. 

Treatment 

This  is  confined  to  general  care  and  management.  In 
the  early  stages  there  are  tendencies  to  suicide  and  dan- 
gerous violence.  Except  in  the  final  stage  all  cases  of 
dementia  prsecox  are  prone  to  impulsive  and  purposeless 
acts. 


68  COMMON  TYPES   OF  INSANITY 

Differential  Diagnosis 

The  distinctions  in  well  developed  cases  from  paranoia 
are  too  obvious  to  call  for  special  mention  ;  those  from 
persecutory  hypochondria  have  already  been  given 
(p.   64). 

Early  cases  of  dementia  paranoides  not  infrequently 
manifest  no  obvious  features  of  dementia  praecox,  but 
simply  present  a  picture  of  recent,  but  more  or  less  sys- 
tematized delusions  of  persecution,  perhaps  mingled 
with  ideas  of  self-importance.  Slight  pedantry  and  an 
occasional  peculiarly  twisted  remark,  the  age  of  the 
patient,  and  above  all  pseudo-hallucinations,  give  the 
key  to  diagnosis. 


4.  SENILE  DELUSIONAL  INSANITY 

This  condition  exhibits  more  of  the  nature  of  an  inde- 
pendent syndrome  than  any  other  of  the  senile  psychoses. 
It  cannot  be  regarded  merely  as  a  phase  of  senile  dementia, 
although  dementia  is  both  its  termination  and  partly 
responsible  for  its  clinical  signs. 

The  onset  is  sometimes  coloured  by  depression  or 
excitement. 

Symptoms 

In  all  essentials  the  clinical  picture  and  course  are 
identical  with  those  of  persecutory  hypochondria.  The 
divergences  from  the  latter  are  here  set  down  : — 

1.  Some  cases  manifest  more  varied  delusions,  occa- 
sionally associated  with  ideas  of  euphoric  character,  or 
jealousy  of  wife's  fidelity. 

2.  A  somewhat  more  placid,  and  at  times  exalted  mood, 
but  one  still  excitable  and  irascible. 


ACUTE  HALLUCINATORY  DELUSIONS        69 

3.  A  certain  degree  of  intellectual  enfeeblement  (not  of 
senile  type  with  loss  of  power  to  retain  recent  impressions 
and  impairment  of  the  power  of  attention,  but  a  narrowing 
of  the  field  of  ideation,  a  certain  poverty  of  thoughts  and 
interests,  and  defective  memory  for  general  and  remote 
events).  Nevertheless  within  its  limits  ideation  and 
mental  action  generally  is  active  enough. 

It  will  be  seen  that  these  distinctions  from  persecutory 
hypochondria  are  merely  due  to  the  super-added  dementia. 
Grandiose  ideas  in  delusional  psychoses  are  indications 
of  mental  dissolution.  The  delusion  of  jealousy  is  com- 
mon in  senile  cases  and  in  alcoholics,  probably  as  the 
result  of  some  real  or  imaginary  (ccenesthetic)  disability 
in  connexion  with  the  sexual  act.  The  more  placid  mood 
is  due  to  affective  blunting,  accompanying  the  general 
impairment. 

We  must,  therefore,  probably  regard  these  cases  of 
senile  delusional  insanity  as  persecutory  hypochondria  of 
delayed  onset.  The  aetiology  of  the  slight  impairment  of 
intellect  present  in  the  disease  is  uncertain.  In  point 
of  fact,  without  the  aid  of  the  history  of  the  case,  types 
which  arise  in  old  people  cannot  be  distinguished  from 
cases  of  persecutory  hypochondria  which  have  grown  old 
in  the  disease  and  the  asylum. 

5.  ACUTE  HALLUCINATORY  DELUSIONS 
("  ALCOHOLIC  MANIA  ") 

This  affection,  like  delirium  tremens,  is  a  psychosis  of 
chronic  alcoholics.  It  merges  through  various  transi- 
tional states  of  confusion,  into  the  definite  clinical  picture 
of  that  disease,  by  which  it  is  sometimes  preceded.  It 
differs  in  its  typical  form  from  delirium  tremens  in  the 
absence  of  clouding  of  consciousness,  imperception,  and 
disorientation  (in  short,  it  is  not  a  delirious  state),  and 


70  COMMON  TYPES  OF  INSANITY 

also  in  the  prominence  of  delusions  and  auditory  hallu- 
cinations. 

Symptoms 

1.  Extravagant  incoherent  delusions  of  persecution. 

2.  Prominent  auditory  hallucinations  ;  chiefly  voices 
uttering  terrifying  threats  and  accusations.  A  few  visual 
hallucinations  not  infrequently  occur  in  the  initial  stage. 

3.  An  emotional  tone  for  the  most  part  of  anxiety  and 
apprehension,  but  showing  at  times  a  half-humorous 
colouring. 

4.  Divertibility  in  mood,  thought,  and  conduct. 

5.  Some  degree  of  motor  restlessness  with  insomnia. 

6.  Good  orientation,  perception,  comprehension  of 
conversation,  and  memory. 

7.  A  sense  of  illness,  and  at  times,  an  insight  into  the 
condition. 

8.  Sometimes  physical  indications  of  alcoholism. 

Prognosis 

The  prospect  of  recovery  is  usually  good  :  the  syndrome 
passing  off  within  a  few  months.  The  usual  alcoholic 
tendency  to  relapse  remains,  and  occasionally  the  affection 
becomes  chronic  in  the  form  of  the  next  condition  to  be 
described. 

Treatment 

These  cases  are  sometimes  suicidal  and  violent  in  the 
more  acute  stages.  In  an  asylum  they  are  usually  no 
trouble,  though  often  restless  at  night.  They  can  be 
persuaded,  at  any  rate  for  the  time,  that  their  hallucina- 
tions are  the  fancies  of  a  disordered  mind,  and  are  calmed 
and  comforted  thereby.     The  only  treatment  needed  is 


CHRONIC  HALLUCINATORY  DELUSIONS    71 

purgation,  a  strychnine  tonic,  and  a  couple  of  drachms  of 
paraldehyde  or  30  grns.  of  Amnion.  Bromide  s.o.s. 

Differential  Diagnosis 

The  distinctions  from  delirium  tremens  have  already 
been  given.  The  diagnosis  from  persecutory  hypochon- 
dria is  based  upon  the  following  points  in  the  alcoholic 
condition  : — 

(a)  The  incoherent  changeable  delusions. 

(6)  The  frequency  and  terrifying  nature  of  the  hallu- 
cinations. 

(c)  The  more  marked  emotional  disturbance,  showing 
considerable  apprehension  alternating  with  frightened 
jocularity. 

(d)  The  divertibility  and  suggestibility. 

(e)  The  sense  of  illness. 

The  divergencies  from  dementia  paranoides  are  obvious, 
e.  g  : — 6,  c,  d,  e,  above,  and  the  absence  of  the  special 
symptoms  of  dementia  precox,  viz  :  basic  apathy,  kata- 
tonia,  speech  abnormalities,  etc. 

The  diagnosis  from  the  confusional  psychoses  previously 
described  is  equally  apparent,  *.  e. ,  there  is  no  delirium 
and  no  continual  motor  excitement. 


6.  CHRONIC  HALLUCINATORY  DELUSIONS 

This  psychosis  may  follow  attacks  of  delirium  tremens 
or  the  last  discussed  syndrome,  or  some  intermediate 
alcoholic  confusional  state.  It  is  simply  an  attenuated 
and  chronic  form  of  alcoholic  "  mania  "  with  symptoms 
of  intellectual  deterioration  super-added,  e.  g.,  all  auto- 
criticism  is  lost. 

The  delusional  content  is  apt  to  be  single  in  the  later 
stages  (influenced  by  the  chronic  auditory  hallucinations, 


72  COMMON  TYPES  OF  INSANITY 

which  are  accusing,  mocking,  threatening  or  inciting,  e.  g., 
commonly  to  indecent  acts),  and  the  erroneous  ideas 
fantastic,  numerous  and  mixed  in  the  earlier  stage,  often 
showing  a  mingling  of  exaltation  and  a  sense  of  persecu- 
tion. 

The  emotional  tone  is  more  humorous  and  less  appre- 
hensive than  is  the  case  in  the  acute  form  ;  childish 
hilarity  is  sometimes  apparent.  The  moods  are  more 
unstable  and  mutable  ;  divertibility  is  well  marked  in 
mood,  but  very  much  less  so  in  thought ;  indeed,  the  delu- 
sions are  for  the  most  part  fixed. 

Alcoholic  intellectual  enfeeblement  manifests  itself 
eventually  in  poverty  of  thought,  loss  of  wider  interests, 
and  mnemonic  defects  (vide  p.  112),  and  immediately,  in 
the  impairment  of  judgment  noted  above. 

With  regard  to  the  prevailing  emotional  tone  ;  in  some 
cases  seen — probably  transition  stages  between  the 
apprehensive  acute  forms  and  the  more  jovial  chronic 
forms — the  still  existing  apprehension  is  accompanied  by 
depression  of  melancholic  morose  type,  which  gives  a 
superficial  colouring  to  the  case  occasionally  liable  to 
be  misleading.  Examination  always  reveals  the  semi- 
humorous  mood. 

Prognosis 

This  is  hopeless,  but  the  progress  of  the  dementia  is 
very  slow. 

Treatment 

No  treatment  is  of  any  avail.  Many  of  these  patients 
are  excellent  asylum  workers.  In  spite  of  the  nature  of 
the  hallucinations  their  conduct  is  good,  and  they  are 
distressed  at  the  suggestion  of  immorality  thus,  as  they 
imagine,  received. 


CHRONIC  HALLUCINATORY  DELUSIONS       73 

Differential  Diagnosis 

Of  the  preceding  conditions,  the  one  which  is  most 
likely  to  be  mistaken  for  the  present  is  persecutory  hypo- 
chondria. The  distinction  is  based  upon  the  presence  in 
the  alcoholic  syndrome  of  :— 

1.  The  semi-humorous  mood,  and  its  instability. 

2.  The  divertibility  and  weakness  of  will. 

3.  The  indications  of  intellectual  and  moral  alcoholic 
impairment  (when  present). 

4.  Upon  the  absence  of  the  chronic  simple  and  typical 
delusions  of  persecutory  hypochondria. 

5.  And  the  predominance  of  hallucinations. 

6.  The  history. 

7.  The  hang-dog  coarsened  appearance  of  the  chronic 
alcoholic,  and  perhaps  other  physical  signs. 

Those  cases  in  which  fantastic  and  exalted  delusions 
are  conspicuous,  and  especially  if  they  are  mingled  with 
persecutory  ideas,  bear  no  inconsiderable  resemblance  to 
general  paralysis.  This  is  the  more  true  if  the  hallucina- 
tions are  temporarily  in  abeyance,  and  the  mood  hilarious 
and  exalted.  Moreover,  there  is  not  a  little  of  the  general 
air  of  futility  of  the  paralytic  manifest  in  some  of  these 
patients.  The  absence  of  physical  signs  of  G.P.I,  enables 
a  diagnosis  to  be  made,  but  apart  from  these  other  useful 
points  of  distinction  are  as  follows  : — Auditory  hallucina- 
tions apart  from  confusional  episodes  do  not  occur  in 
G.P.I.  The  memory  for  times  and  dates  in  the  alcoholic 
condition  is  relatively  unimpaired  and  the  ability  to  do 
simple  sums  (if  ever  present)  is  retained.  The  mental 
action  generally  is  quicker  and  more  active  than  would 
be  the  case  in  a  paralytic  who  manifested  such  fantastic 
delusions  as  do  these  alcoholics.  The  delusions  are  also 
in  some  cases  added  to,  by  a  process  of  endless  pseudo- 
reminiscence  on  the  part  of  the  alcoholic. 


74  COMMON  TYPES  OF  INSANITY 

7.  ALCOHOLIC  "  PARANOIA  " 

The  so-called  alcoholic  paranoia  is  another  of  the 
psychoses  of  chronic  alcoholism.  In  its  typical  form, 
with  more  or  less  systematized  delusions  of  persecution 
or  grandeur,  it  is  rare.  And  it  is  not  unlikely  that  such 
cases  are  dependent  in  part  upon  a  paranoical  tempera- 
ment in  the  patient. 

The  more  common  form  presents  the  following  : — 

Symptoms 

1.  Delusions  ;  possible  in  content,  usually  few,  and 
almost  invariably  based  upon  the  idea  of  infidelity, 
depravity,  robbery,  on  the  part  of  some  relation,  friend 
or  acquaintance.  Conjugal  infidelity  is  by  far  the  com- 
monest idea. 

2.  Misconstruction  of  events  connected  with  the  objects 
of  the  delusion,  to  reinforce  them. 

3.  A  mood  dangerous,  angry,  or  resentful,  yet  becoming 
at  times  semi-humorous.  But  in  an  asylum  the  emotional 
tone  is  for  the  most  part  normal.  The  departures  from 
the  normal  mood  are  logical  given  the  truth  of  the  delu- 
sion, and  neither  in  excess  nor  abnormally  insignificant. 

4.  Complete  collectedness,  with  good  understanding  of 
the  general  situation. 

5.  Absent  or  only  very  occasional  hallucinations,  except 
at  the  onset,  which  may  be  marked  by  some  acute  alcoholic 
syndrome. 

6.  Symptoms  of  alcoholic  intellectual  and  moral  im- 
pairment, e.  g.,  poverty  of  thought,  circumscribed  mental 
outlook,  defects  of  memory  (especially  for  recent  events) 
and  of  power  of  attention,  irritability,  selfishness,  lying, 
brutalization  of  conduct. 

7.  Physical  signs  of  chronic  alcoholism,  e.  g.,  coarse 
tremors  of  fingers  and  tongue,  increased  or  absent  knee- 


ALCOHOLIC   "PARANOIA"  75 

jerks,  peripheral  neuritis,  slurred  speech.  The  absence 
of  these  signs  is  of  no  significance.  The  characteristic 
facial  appearance  and  demeanour. 

Prognosis 

The  prognosis  is  bad.  Some  cases  lose  their  delusions 
after  a  short  time  in  the  asylum,  but  almost  invariably 
relapse  when  discharged.  About  an  equal  number  make 
no  improvement,  but  remain  unchanged  for  many  years, 
finally  and  gradually  becoming  definitely  weak-minded. 

Treatment 

Treatment  simply  consists  in  the  suggestion  of  the  idea 
of  abstinence  from  alcohol,  and  confinement  in  an  asylum. 
In  most  cases  permanent  detention  is  desirable,  but,  when 
the  delusions  disappear,  impossible  under  existing  condi- 
tions. Prior  to  admission,  these  cases  are  often  brutal 
in  conduct  and  ill-use  and  occasionally  kill  their  spouses, 
but  as  asylum  patients,  being  blustering  but  cowardly 
bullies,  they  are  usually  well  behaved. 

Differential  Diagnosis 

(A)  From  Paranoia  : — 

In  the  alcoholic  condition  as  here  considered,  the 
delusions  are  not  continually  growing  and  widening  by  a 
process  of  misconstruction  of  unconnected  events  into  a 
systematised  delusionary  outlook  upon  life.  The  symp- 
toms of  deterioration  enumerated  in  (6)  on  the  previous 
page  do  not  occur  in  paranoia,  which,  moreover,  has  no 
definite  onset  nor  semi-humorous  mood. 

(B)  From  Persecutory  Hypochondria  : — 

The  different  type  of  delusion,  the  absence  of  prominent 
hallucinations,    the   alcoholic   mood   and   emotional   re- 


16  COMMON  TYPES  OF  INSANITY 

action,  the  symptoms  of  mental  and  moral  and  physical 
impairment,  taken  together,  sufficiently  separate  the  two 
conditions. 

8.  DELUSIONAL  STATES  IN  G.P.I. 

The  majority  of  general  paralytics  manifest  delusions, 
which  in  many  cases  are  predominant  during  some  phase 
of  the  disease.  The  delusional  states  take  many  forms 
and  merge  on  the  one  hand  into  depression,  and  on  the 
other  into  excitement,  while,  as  is  the  case  in  all  the 
syndromes  of  G.P.I.,  a  steady  mental  deterioration  co- 
exists throughout. 

Two  main  varieties  may  be  described  : — 

(A)  Those  dependent  upon  euphoria. 

(B)  Those  dependent  upon  feelings  of  disability. 
Then,  again,  the  combination  of  these  two  ccenesthetic 

states  is  common  in  general  paralysis. 

The  first  form  comprises  the  classical  megalomaniacal 
or  expansive  group. 

The  second  division  embraces  two  classes  of  syn- 
dromes : — 

1.  Hypochondriacal  and  persecutory  forms. 

2.  Paranoidal  varieties. 

(A)  THE  EXPANSIVE  FORMS 

The  megomaniacal  excitement  has  been  described  in 
Chapter  I.  Here  it  is  necessary  to  consider  a  condition 
in  which  excitement  is  inconspicuous  and  expansive 
delusions  prominent. 

Symptoms 

1.  Delusions  of  grandeur,  wealth,  or  vast  ability, 
accompanied  by  glowing  hopes  and  exaggerated  im- 
possible plans.  These  erroneous  ideas  are  for  the  most 
part  disconnected  and  changeable,  but  unshaken  by  con- 


DELUSIONAL  STATES  IN  G.P.L  77 

tradiction.  The  indication  of  their  impossibility  merely 
results  in  amplifications  and  the  advancement  of  absurd 
arguments  and  explanations  in  their  support.  (This  is 
the  meaning  of  the  term  expansive  delusions.) 

Except  in  the  early  stages,  the  delusions  exert  little 
influence  upon  the  patient's  reaction  to  his  environment. 

2.  Relative  emotional  dullness.  The  delusions,  absurd 
as  they  are,  are  often  stated  with  indifference  although 
a  certain  boastfulness  of  manner  may  be  present. 

3.  Volitional  feebleness,  and  divertibility  of  mood  and 
conduct. 

4.  Intellectual  impairment,  shown  by  defects  of  mem- 
ory, acuity  of  perception,  attention,  interest,  and  mental 
activity  generally,  of  varying  degrees  up  to  definite 
dementia  (vide  p.  98). 

5.  Physical  signs  of  G.P.L 

Differential  Diagnosis 

This  phase  of  the  disease  is  not  likely  to  be  mistaken 
for  anything  else,  but  certain  other  conditions  may  require 
careful  observation  to  distinguish  them  from  it. 

1.  The  excited  phases  of  alcoholic  pseudo-paresis  have 
been  referred  to  on  page  36.  In  its  quieter  periods  it  of 
course  resembles  the  state  under  discussion.  The  chief 
points  of  importance  in  the  diagnosis,  viz.  the  physical 
signs,  are  detailed  on  page  37.  The  distinctions  between 
chronic  hallucinatory  delusions  and  G.P.L  are  given  on 
p.  73. 

2.  The  distinctions  between  senile  exaltation  with  ex- 
citement and  G.P.L  have  been  indicated  on  page  47  and 
hold  good  for  the  same  conditions  without  excitement. 

3.  Dementia  paranoides  with  grandiose  delusions  may 
superficially  resemble ,  this  phase  of  general  paralysis. 
The  latter  is  distinguished  by  the  presence  of  : — Euphoria, 


78  COMMON  TYPES  OF  INSANITY 

true  expansive  delusions,  divertibility  in  mood  and  con- 
duct, defects  of  memory,  and  physical  signs  :  and  by  the 
absence  of  katatonia,  the  speech  abnormalities  of  dementia 
praecox,  motiveless  conduct  and  chronic  hallucinations  of 
hearing,  especially  pseudo-hallucinations  (vide  Glossary). 


(B)    DELUSIONS    DEPENDENT   UPON   AN   UNPLEASANT 
CCENESTHESIS 

I.  Hypochondriacal  and  Persecutory  Forms 

These  varieties  merge  by  imperceptible  gradations  into 
the  depressed  phase  of  general  paralysis  (vide  p.  56)  and  in 
fact  only  differ  from  the  latter  in  the  absence  or  insignifi- 
cance of  that  mood. 

The  delusional  state  may  be  of  a  hypochondriacal 
nature  only  (e.  g.,  head  made  of  glass,  bowels  turned  into 
worms),  or  include  ideas  of  persecution — changeable  and 
exaggerated.  The  delusions  not  infrequently  show  an 
admixture  with  ideas  of  grandeur,  and  the  presence  of  a 
passing  euphoria  (e.  g.,  that  the  bowels  are  obstructed 
by  diamonds  or  bank-notes). 

Intellectual  and  volitional  impairment  together  with 
relative  emotional  indifference  (in  view  of  the  nature  of 
delusions),  and  absence  of  proper  emotional  reaction  as 
noted  under  the  last  syndrome  are  also  present. 

The  delusional  content  may  be  of  similar  type  to  that 
of  persecutory  hypochondria,  dementia  paranoides,  or 
melancholia. 

Differential  Diagnosis 

1.  From  Persecutory  Hypochondria: — 

Present  in  G.P.I. : 

Intellectual  impairment,  e.  g.,  defective  perception, 
association  and  memory  ;    divertibility  in  mood 


DELUSIONAL  STATES  IN  G.P.I.  79 

and  conduct ;    indications   of  euphoria   breaking 
through  a  mood    of  relative    indifference  to  the 
unpleasant  delusions. 
Absent  in  G.P.I.  : 

Persistent  prominent  hallucinations,  excitability, 
moods  of  considerable  intensity  with  proper  emo- 
tional reaction  and  in  proportion  to  the  nature  of 
the   delusion ;    conduct  in  accordance  with  the 
same ;     remissions   as   noted   under   persecutory 
hypochondria. 
2.  When   katatonia   and   auditory   hallucinations,    or 
pseudo-hallucinations    are    not    at    once    prominent    in 
dementia  paranoides,  the  distinction  of  late  developing 
types  from  general  paralysis  is  not  always  easy.     Impair- 
ment of  acuity  of  perception  and  of  memory,  especially 
for  times  and  dates,  divertibility  of  mood  and  conduct, 
and  inability  to  do  simple  calculations  point  to  G.P.I. 
Mannerisms,  purposeless  acts,  and  the  speech  abnor- 
malities,   e.  g.,    neologisms,    verbigeration,    meaningless 
phrases,  point  to  dementia  prsecox.     Physical  signs  of 
G.P.  are  of  course  conclusive  evidence. 

II.  Paranoidal  Delusions  in  General  Paralysis 

The  syndrome  considered  here  is  uncommon,  and 
possibly  its  symptomatology  is  in  part  based  upon  a 
paranoiacal  temperament  in  the  patient,  i.  e.,  the  occur- 
rence of  the  disease  general  paralysis  in  an  individual 
already  constitutionally  abnormal. 

It  occurs  in  the  early  stages  of  G.P.I,  and  resembles 
an  incompletely  evolved  case  of  querulent  paranoia. 

The  delusions  of  persecution  are  possible  and  attributed 
to  living  persons,  e.g.,  a  conspiracy  organized  by  some 
individual  whom  the  patient  dislikes  "  to  get  him  out  of 
the  way,"  etc. 

The  delusions  are  logical,  and  the  conduct  in  accordance 


80  COMMON  TYPES   OF  INSANITY 

with  them.  They  show  some  systematization,  a  fitting  in 
of  some  past  or  current  unpleasant  incidents  with  the 
scheme  of  present  imaginary  persecution.  There  are  no 
appreciable  demential  symptoms  ;  volition  and  emotional 
reaction  are  normal.  The  demeanour  is  dignified  and 
manifests  the  increased  self-esteem  of  the  paranoiac. 

These  patients  resent  their  admission  to  the  asylum 
in  a  perfectly  normal  manner.  Prior  to  this,  they  have 
not  infrequently  retaliated  upon  their  imaginary  persecu- 
tors. Physical  signs  of  G.P.I,  are  usually  absent  or  very 
indefinite. 

Now  there  are  three  points  to  which  the  attention  of 
the  observer  should  be  directed  in  order  to  clear  up  the 

Diagnosis 

1.  An  exaggerated  statement  expressing  a  degree  or 
kind  of  emotion  or  attitude  of  mind  that  is  not  in  accord- 
ance with  the  patient's  conduct,  emotional  state,  or 
former  character,  should  raise  a  very  strong  suspicion  of 
G.P.I. 

2.  The   possibility    of — 

(a)  Discovering   any   doubt   or   uncertainty  in   the 

patient's  mind  concerning  his  delusions. 
(6)  Persuading  him  to  disbelieve  any  part  of  them. 
In  paranoia  neither  feat  is  possible. 

3.  The  fact  that  the  conduct  of  paranoiacs  does  not 
bring  them  into  conflict  with  their  environment,  and  hence 
into  asylums,  until  the  systematization  of  their  delusions 
is  complete  up  to  the  present.  In  other  words  a  paranoiac 
does  not  advertise,  nor  act  anti-socially  upon  his  erroneous 
judgments  until  they  are  logically  co-ordinated  into  a 
delusionary  whole. 

The  resemblance  of  these  paranoidal  syndromes  in 
G.P.I,  to  the  more  systematised  varieties  of  alcoholic 


PARANOIDAL  AMENTIA  81 

paranoia  (vide  p.  74)  is  marked.  In  most  cases  the  correct 
diagnosis  can  only  be  reached  by  observing  the  following 
points  : — 

(a)  The  presence  or  absence  of  definite  alcoholic  de- 
terioration, mental  and  moral  (not  always  easy  to  dis- 
tinguish from  paralytic  impairment)  (vide  Dementia, 
p.  112). 

(b)  The  presence  or  absence  of  a  latent  euphoria. 

(c)  Careful  note  of  the  physical  signs  (vide  p.  99). 
Then,  of  course,  these  paranoidal  paralytics  may  also 

be  alcoholics.  In  which  case  the  main  point  is  to  decide 
upon  the  presence  or  absence  of  G.P.I. 

The  history  when  available  is  a  valuable  aid  to  a  correct 
diagnosis.  The  anti-social  conduct  of  paranoiacs  and 
alcoholics  comes  as  no  surprise  to  their  acquaintances, 
because  these  two  types  have  been  gradually  evolving  and 
degenerating  respectively,  to  the  level  indicated  by  the 
present  anti-social  acts  which  have  brought  them  into 
conflict  with  their  environment  and  hence  under  observa- 
tion. Their  causative  change  of  character  has  been  a 
matter  of  years.  The  delusions  of  the  paranoidal 
paralytic  are  a  comparatively  sudden  development  and 
indicate  a  relatively  abrupt  change  in  personality,  which 
could  only  be  the  result  of  recently  acquired  disease. 

9.  PARANOIDAL  AMENTIA 

This  syndrome  is  a  mild  variety  of  amentia,  in  which 
the  clouding  of  consciousness  is  slight  and  delusions  are 
prominent. 

Symptoms 

1.  Delusions  of  almost  any  content,  often  vague, 
confused,  and  contradictory,  but  implicitly  believed  in. 
The  faith  in  the  delusions  can  however  often  be  transi- 
torily shaken  by  suggestive  conversation. 

e.m.d,  6 


82  COMMON  TYPES  OF  INSANITY 

2.  A  changeable  but  sincere  and  fervent  mood,  mani- 
festing great  intensity  of  feeling,  in  accordance  with  the 
delusions.  Commonly  apprehension,  with  ideas  of  perse- 
cution, is  present. 

3.  Conduct  appropriate  to  the  delusions. 

4.  Mental  confusion,  but  no  inaccessibility  or  imper- 
ception. 

5.  Hallucinations. 

6.  Cachexia. 

Differential  Diagnosis 

1.  From  Dementia  Paranoides  : — 

The  following  features  of  the  amential  syndrome  are 
the  basis  of  the  distinction  : — 

i.  The  sincerity  and  depth  of  the  emotional  dis- 
turbances, 
ii.  Mental  confusion  (i.  e.,  concerning  external  events 

etc.). 
iii.  Conduct  in  accordance  with  the  erroneous  ideas, 
iv.  Cachexia,  and  short  duration  of  the  attack, 
v.  Absence     of    katatonia,     catalepsy,     motiveless 
conduct,  etc. 

2.  From  Paranoia  : — 

The  distinguishing   symptoms  from  paranoia  are : — 
i.  Acute  onset,  and  short  duration, 
ii.  Great  emotional  disturbance. 
iii.  Confusion,  and  sometimes  disorientation, 
iv.  Cachexia. 

v.  Hallucinations  (cf.  p.  62). 

.vi  Absence  of  logical  connexion  between  the  delu- 
sions, and  of  their  gradual  development  upon  a 
basis  of  preconception. 

3.  Persecutory  hypochondria  is  excluded  by  the  pres- 
ence in  the  amential  syndrome    of  violent  emotional 


THE  POLYNEURITIC  PSYCHOSIS  83 

conditions,  confusion,  cachexia,  short  duration,  more 
continual  hallucinations,  absence  of  fixity  in  type  of 
delusions. 

Persecutory  hypochondria,  however,  occasionally  be- 
gins with  an  episode  of  acute  confusion.  These  cases 
like  all  other  mixed  insanities  are  difficult  to  diagnose. 
The  confusion  is  marked  by  an  absence  of  rapid  changes  . 
in  mood,  and  indeed,  the  general  emotional  condition  is 
much  less  intense  than  in  true  amentia  agitata. 

The  patient  talks  incoherently,  plays  upon  words 
but  does  not  display  disintegration  of  words,  or  meaning- 
less speech.  Again,  he  is  more  accessible  than  is  the  case 
in  true  amentia. 

The  distinction  of  these  conf  usional  states  in  persecutory 
hypochondria  from  paranoidal  amentia  are  based  upon 
the  depth  of  the  confusion  together  with  the  relatively 
apathetic  mood,  in  the  former. 

4.  From  Delusional  States  in  G.P.I. : — 

The  chief  points  in  the  diagnosis  are  : — The  shallow 
emotions  or  apathy  of  G.P.I,  and  the  physical  signs.  The 
confusion,  hallucinations,  and  the  absence  of  general 
mnemonic  and  intellectual  impairment,  in  amentia. 

5.  Alcoholic  "  mania  "  is  distinguished  by  a  semi- 
humorous  mood,  uncertainty  of  the  delusionary  ideas, 
divertibility  in  mood  and  thought,  physical  signs  of 
alcoholism,  the  prominence  and  persistence  of  hallucina- 
tions of  hearing. 

10.  THE   POLYNEURITIC    PSYCHOSIS    (Korsakoff's 
Syndrome) 

This  condition  is  an  attenuated  variety  of  intoxication, 
i.  e.,  confusional  insanity,  due  in  the  vast  majority  of 
cases   to    chronic    alcoholism.     Other   toxins,    howeyer, 


84  COMMON  TYPES   OF  INSANITY 

productive  as  a  rule  of  diverse  forms  of  confusion,  may 
occasionally  produce  Korsakoff's  syndrome.  This  latter, 
when  fully  established,  differs  from  the  other  forms  of 
confusional  insanity  in  the  insignificance  of  the  clouding 
of  consciousness,  in  the  presence  of  peripheral  neuritis, 
as  well  as  in  the  following  features  : — 

1 .  The  presence  of  prominent  but  shifting  and  change- 
able delusions  in  reference  to  the  past,  resulting  from  the 
characteristic  pseudo-reminiscence.  These  patients  re- 
late long  histories,  more  or  less  confused,  of  imaginary 
past  incidents.     Amnesia  for  recent  events  is  marked. 

2.  Slight  clouding  of  consciousness  with  only  occasional 
disorientation. 

3.  Moderately  good  passive  attention. 

4.  Accessibility,  suggestibility,  and  divertibility,  except 
that  the  patient  cannot  be  persuaded  of  the  inaccuracy  of 
his  delusions. 

5.  Absence  of  continuous  hallucinations,  except  in  the 
initial  stage,  which  may  be  ushered  in  by  delirium  tremens 
or  some  other  acute  alcoholic  or  amential  syndrome. 

Prognosis 

Cases  of  a  year's  duration  may  recover.  As  a  rule  a 
longer  duration  means  permanent  insanity  ending  in 
dementia. 

Differential  Diagnosis 

The  characteristic  combination  of  features  in  this 
malady,  viz. — polyneuritis,  gross  falsification  of  memory, 
and  confusion  are  as  a  rule  distinctive.  Nevertheless, 
other  chronic  alcoholic  syndromes  may  show  some  of  the 
cardinal  symptoms  of  this  affection.  This  has  been  noted 
under  chronic  hallucinatory  delusions  in  reference  to 
pseudo-reminiscence.     Indeed,    all    the    alcoholic    syn- 


THE   POLYNEURITIC   PSYCHOSIS  So 

dromes  merge  into  each  other,  and  occur  mixed,  almost 
as  frequently  as  they  do  separately.  (Incidentally,  the 
same  statement  holds  good  concerning  the  relationship 
between  all  the  epileptic  syndromes,  the  paralytic,  confu- 
sional,  and  the  dementia  praecox  psychoses,  etc.,  as  noted 
under  their  respective  headings.) 


CHAPTER  IV 

STATES  OF  STUPOR 

The  term  stupor  may  be  used  in  a  wide  sense  to  include 
those  syndromes  of  mental  disorder  in  which  the  pre- 
dominant signs  are  varying  degrees  of  immobility  and 
mutism.  When  absolute,  the  different  varieties  are 
almost  impossible  to  diagnose,  nor  are  they  always  easy 
when  the  stupor  is  less  marked. 

1.  CIRCULAR  STUPOR 

This  condition  is  a  phase  of  manic-depressive  insanity, 
allied  to  melancholia,  in  which  the  impediment  of  will  is 
sufficient  to  produce  stupor.  It  is  termed  circular  owing 
to  its  recurrent  character,  but  the  subsequent  attacks 
may  take  the  form  of  other  manifestations  of  the  manic- 
depressive  diathesis,  viz. — mania,  melancholia,  or  mix- 
tures of  the  two,  which  may  also  have  preceded  the  stupor. 

Symptoms 

1.  Immobility,   at  most  occasional  slow  movements. 

2.  Mutism,  though  often  a  whispered  reply  may  be 
obtained  upon  earnest  persuasion.  These  result  from 
impediment  of  volition. 

3.  Genuine  depression  with  sad  appearance. 

4.  Usually,  delusions  of  melancholic  character. 

5.  Collectedness  with  good  perception,  comprehension, 
orientation,  and  memory. 

86 


KATATONIC  STUPOR  87 

Prognosis  and  Treatment 

These  are  along  the  same  lines  as  for  melancholia,  and 
need  little  special  comment.  The  patient  should  be  kept 
in  bed.  Special  attention  should  be  paid  to  the  skin  of 
the  back,  etc.  He  should  be  fed  by  tube  if  necessary,  at 
least  three  times  a  day.  It  is  important  to  remember 
that  these  stuporose  patients  often  suffer  from  insomnia, 
just  as  much  as  melancholies.  They  need  as  much  feeding 
up  and  as  many  aperients  ;  they  are  also  benefited  by 
massage.  They  are  suicidal  in  many  cases,  as  the  stupor 
is  developing  or  passing  off. 

2.  KATATONIC  STUPOR 

Katatonic  stupor  is  a  well-marked  phase  of  dementia 
prsecox,  and,  indeed,  evinces  all  the  typical  features  of 
that  malady,  perhaps  more  fully  than  any  other  manifest- 
ation. It  is  a  volitionally  active  stupor,  the  result  of  a 
perverted  but  powerful  action  of  the  will,  without  motive 
or  psychical  representation. 

Symptoms 

1.  Immobility. 

2.  Mutacismus  (forced  dumbness). 

3.  Emotional  vacuity. 

4.  Other  katatonic  or  cataleptic  features  {vide  Glossary). 

5.  Good  comprehension,  perception,  orientation  and 
memory. 

6.  Transitory  attacks  of  other  phases,  i.  e.,  excite- 
ment or  depression. 

Prognosis 

Temporary  recovery  sometimes  occurs,  to  be  followed 
later  by  relapse  into  the  same  or  some  other  variety  of 


88  COMMON  TYPES  OF  INSANITY 

the  disease.  More  commonly,  the  stupor  merges  directly 
into  one  of  the  latter,  and  the  malady  progresses  without 
intermission.  The  temporary  recoveries  may  persist 
for  years,  but  usually  they  are  not  complete,  a  degree  of 
stolidity,  and  seclusiveness  remaining.  Some  cases 
amongst  those  that  are  recorded  as  recoveries  are  examples 
of  amentia  with  katatonic  signs  (see  p.  183). 

Treatment 

There  is  no  special  treatment  indicated.  Tube  feeding 
may  be  needed  for  a  while,  and  the  patient  should  be 
kept  in  bed  during  the  acute  stage.  One  should  be 
prepared  for  sudden  purposeless  violence,  destructiveness 
or  suicide.  These  cases  are  often  wet  and  dirty  in  habits 
and  so  require  a  good  deal  of  attention. 

Differential  Diagnosis 

The  distinctions  from  circular  stupor  are  the  presence 
of  katatonic  or  cataleptic  signs,  e.  g.,  negativism,  stereo- 
typy (vide  Glossary),  transitory  excitement  or  exaltation, 
if  they  occur  ;  and  the  absence  of  genuine  unhappiness 
and  impediment  of  will. 

Cases  of  katatonic  stupor  often  strike  absurd  or  un- 
natural attitudes.  Not  uncommonly  the  dementia 
prsecox  smile  may  at  times  be  seen — a  smile  that  is 
causeless,  vacant  and  silly  or  sly.  This  smile  at  once 
excludes  a  diagnosis  of  circular  stupor.  The  dumbness 
in  the  latter  is  seldom  absolute.  It  is  due  to  an  impedi- 
ment of  will  which  the  patient  vainly  tries  to  overcome  ; 
the  effort  can  be  observed,  and  moreover,  is  commonly 
successful  to  the  extent  of  a  much  delayed  whispered 
response  to  a  question.  The  katatonic  patient  will  not 
speak.  He  does  not  know  why,  but  he  is  fixed  and 
immovable  in  his  determination.     Exactly  the  same  state 


AMENTIA  ATTONITA  89 

of  affairs  appertains  in  the  realm  of  ordinary  action. 
Katatonic  cases  will  not  do  what  they  are  asked  ;  bad 
cases  of  circular  stupor  fail  to  do  so  because  they  cannot. 
Actual  negativism  is  almost  always  present  in  katatonic 
stupor,  never  in  the  circular  variety,  although  a  certain 
amount  of  resistiveness,  arising  from  apprehension,  may 
be  manifest  {vide  Melancholia,  p.  50). 

3.  AMENTIA  ATTONITA 

This  affection  is  a  variety  of  acute  confusional  insanity. 
It  is  a  passive  stupor  due  to  a  high  degree  of  clouding 
of  consciousness.  The  patient  does  not  act  or  speak, 
because  he  has  no  clear  ideas  to  produce  motives. 

Symptoms 

1.  Acute  onset. 

2.  Cachexia. 

3.  Immobility  and  mutism,  more  or  less  absolute. 

4.  Semi-consciousness,  inaccessibility,  imperception, 
disorientation. 

5.  Temporary  lucid  intervals,  in  which  is  manifest 
amnesia  for  events  during  the  illness. 

6.  Apparent  emotional  indifference. 

Prognosis  and  Treatment 

In  all  essentials  the  prognosis  and  treatment  are 
identical  with  those  of  amentia  agitata. 

Differential  Diagnosis 

1.  From  Circular  Stupor  : — 

The  presence  of  clouding  of  consciousness,  imperception, 
cachexia,  disorientation,  and  the  absence  of  depression, 


90  COMMON  TYPES  OF  INSANITY 

ideation,  and  memory — in  amentia,  are  the  main  diag- 
nostic features. 

As  noted  above  the  stupor  in  amentia  is  due  to  an 
absence  of  mental  pictures  of  internal  or  external  origin, 
necessary  to  produce  motives  for  volition.  Circular 
stupor  is  due  to  an  impediment  of  will,  which  the  patient's 
promptings  to  action  cannot  overcome. 

2.  From  Katatonic  Stupor  : — 

The  distinctions  are  obvious.  In  simple  amentia, 
there  is  the  semi-consciousness,  imperception,  etc.,  and 
no  katatonia  ;  in  katatonic  stupor,  katatonia  or  catalepsy 
together  with  clearness  about  surroundings.  (But  see 
p.  182.) 

4.     SIMPLE  STUPOR  IN  DEMENTIA  PRECOX 

This  is  a  variety  of  stupor  without  katatonia  or  cata- 
lepsy, but  manifesting  rapid  changes  of  feeling,  and  as  a 
rule,  hallucinations  and  delusions. 

From  amentia,  it  is  distinguished  by  the  absence 
of  clouding  of  consciousness,  amnesia,  imperception, 
disorientation  and  inaccessibility,  cachexia,  and  lucid 
intervals. 

The  diagnosis  from  circular  stupor  is  based  upon  the 
presence  in  dementia  prsecox  of  hallucinations,  and  the 
absence  of  persistent  and  genuine  misery. 

The  basic  apathy  of  dementia  prsecox  is  manifest  in 
this  simple  stuporose  condition.  The  patients  frequently 
express  apprehension  and  more  or  less  gross  delusions, 
e.  g.,  that  their  eyes  are  about  to  be  gouged  out,  but  they 
show  very  little  distress. 

There  is  one  symptom  that  I  have  observed  in  these 
patients,  which  I  believe  is  not  found  in  any  other  variety 
of  stupor.  That  is  a  subjective  state  of  "  puzzling."  With 
complete  clearness  about  the  status  quo  and  the  surround- 


EPILEPTIC  STUPOR  91 

ings,  the  patient  is  confused  about  himself,  about  his 
feelings  and  the  ideas  that  come  into  his  head.  He  has 
at  first  some  recognition  that  he  is  ill,  yet  he  cannot 
understand  his  thoughts,  delusions,  or  hallucinations, 
which  to  him  are  an  incomprehensible  set  of  realities, 
nevertheless  in  the  early  stages  he  can  be  made  to  under- 
stand temporarily  to  some  extent  that  they  are  due  to 
the  illness. 

This  condition  is  manifest  in  a  peculiar  puzzled  stare, 
in  the  indefinite  and  halting  fashion  in  which  he  expresses 
himself,  in  the  aimless  way  in  which  he  wanders  or  stands 
about,  and  by  some  patients,  it  is  expressed  in  words. 

These  cases  often  initiate  hebephrenia,  that  variety 
of  dementia  prsecox  in  which  katatonia  is  inconspicuous 
throughout  and  in  which  emotional  disturbances  are  much 
in  evidence.  In  the  writer's  opinion  this  self-puzzled 
state  occurs  at  the  genesis  of  all  forms  of  dementia  prsecox 
and  is,  moreover,  peculiar  to  that  malady.  As  the  disease 
progresses,  it  is  gradually  lost.  Early  cases  manifest- 
ing it  can  by  careful  therapeutic  conversation,  suitable 
environment  and  treatment,  be  retarded  in  their  progress. 

5.  EPILEPTIC  STUPOR 

Stupor  in  epileptics  is  an  "equivalent,"  and  is  asso- 
ciated with  fits  or  other  equivalents,  e.  g.,  excitement 
or  depression. 

Symptoms 

1.  Sudden  temporary  stupor,  accompanied  by  more 
or  less  immobility  and  mutism. 

2.  Considerable  clouding  of  consciousness  and  inac- 
cessibility. 

3.  Short  interludes  of  delirium  with  motor  excitement. 

4.  Slow,  clumsy  intellectual  and  bodily  action,  and  also 
speech  when  present. 


92  COMMON  TYPES  OF  INSANITY 

Prognosis 

As  epileptic  delirium. 

Treatment 

No  special  treatment  is  indicated.  An  aperient  should 
be  given,  and  as  a  precaution  it  is  advisable  in  most  cases 
to  keep  the  patient  in  bed  in  a  single  room.  When  very 
"lost,"  he  may  stumble  about  and  hurt  himself  ;  when 
delirious  he  may  attack  others. 

As  it  will  be  inferred,  these  cases  are  simply  stuporose 
varieties  of  epileptic  delirium,  bearing  a  similar  relation 
to  that  condition  as  amentia  attonita  does  to  amentia 
agitata.     And  they  should  be  treated  as  such. 

Differential  Diagnosis 

Of  the  preceding  varieties  of  stupor  described,  amentia 
attonita  is  the  only  one  showing  any  real  resemblance  to 
epileptic  stupor.  Consciousness  is  to  a  great  extent 
unaffected  in  the  others. 

The  points  to  bear  in  mind  in  the  distinction  from 
amentia,  are  the  sudden  onset  without  cachexia,  the  short 
duration,  and  the  appearance  of  phases  of  motor  excite- 
ment. Even  apart  from  the  latter,  the  epileptic  practic- 
ally always  shows  some  signs  of  both  intellectual  and 
emotional  activity,  which  is  of  characteristic  oppressed 
clumsy  retarded  type,  whereas  the  ament  is  apparently 
devoid  of  all  thought  and  emotion.  One  may  perhaps 
compare  the  epileptic  stuporose  patient  to  a  motor  car 
which  in  spite  of  petrol  will  only  produce  spasmodic 
jerks  and  grunts,  because  its  carburetter  is  sooted,  in 
contrast  to  the  ament  who  may  be  likened  to  a  car  in 
which  the  petrol  is  turned  off. 


STUPOR  IN  GENERAL  PARALYSIS    93 

6.  STUPOR  IN  GENERAL  PARALYSIS 

Stupor  is  usually  a  transient  phase  in  G.P.I,  charac- 
terized by  varying  degrees  of  immobility  and  mutism  and 
by  the  presence  of  other  signs  of  the  disease,  e.  g.,  occa- 
sional expansive  delusions,  or  ideas  of  an  unpleasant 
nature  marked  by  a  latent  euphoria,  mnemonic  defects, 
and  other  symptoms  of  intellectual  impairment ;  and, 
physical  signs.  If  the  stupor  always  took  this  form,  the 
diagnosis  would  be  simple,  but  unfortunately  such  is  not 
the  case.  Prolonged  attacks  of  stuporose  confusion 
occasionally  occur  which  present  no  inconsiderable 
resemblance  to  amentia  attonita. 

All  varieties  of  stupor  in  G.P.I,  manifest  some  degree 
of  clouding  of  consciousness,  and  for  that  reason  may  be 
regarded  as  stuporose  and  mild  forms  of  paralytic  de- 
lirium. 

Prognosis 

The  majority  of  attacks  only  last  a  few  days  or  a  week 
or  so,  some  however  may  persist  for  four  months 
or  longer.  These  prolonged  types  show  remissions, 
increasing  in  length  as  the  stupor  begins  to  pass 
off,  and  are  sometimes  followed  by  a  period  of 
approximate  normality,  not  uncommonly  terminated 
by  an  attack  of  megalomania.  So  complete  does 
the  temporary  recovery  appear  when  the  stupor 
has  cleared  up,  that  in  some  cases  one  momentarily 
doubts  the  diagnosis,  especially  when  the  physical  signs 
clear  up  too — an  occasional  coincidence. 

Treatment 

As  a  rule  these  patients  do  not  refuse  food,  although 
spoon  feeding  may  be  necessary  occasionally.     All  cases 


94  COMMON  TYPES  OF  INSANITY 

should  be  kept  in  bed,  and  the  bowels  and  bladder  care- 
fully attended  to.  Retention  of  urine  is  sometimes 
present,  but  far  more  commonly  incontinence  of  both  urine 
and  faeces. 

The  skin  toilette  must  be  scrupulously  carried  out 
(vide  p.  27). 

Differential  Diagnosis 

1.  From  Circular  Stupor  : — 

The  main  points  to  be  noted  are  the  presence  of  the 
paralytic  symptoms  and  signs  noted  above,  and  the  ab- 
sence of  deep  unhappiness  and  impediment  of  will.  Some 
degree  of  confusion  or  imperception  is  present  in  the 
paralytic  condition  and,  not  uncommonly,  disorientation. 

2.  From  Katatonic  Stupor  the  distinctions  are  usually 
obvious. 

3.  From  Amentia  Attonita  : — 

As  noted  above  some  of  the  stuporose  paralytics  bear  a 
close  resemblance  to  stuporose  aments.  They  he  in  bed 
motionless  and  apparently  mindless,  they  do  not  speak  or 
appear  to  understand  what  is  said  to  them.  They  are  to 
some  extent  cachetic,  and  when  nearing  the  end  of  the 
attack,  remissions  appear,  in  which  they  are  lucid,  but 
evince  amnesia  for  the  illness. 

Remissions  in  physical  signs,  perhaps  already  indefinite, 
render  the  diagnosis  more  difficult.  Remissions  in 
physical  signs  in  G.P.I,  are  not  confined  to  the  stuporose 
types  of  the  disease,  by  the  way,  but  are  exceedingly 
common  in  all  varieties.  That  is  to  say,  pupillary  changes, 
patellar  reflexes,  tongue  signs,  and  tremors,  bladder  and 
rectal  indications,  all  vary  from  normal  to  abnormal 
from  time  to  time. 


MANIACAL  STUPOR  95 

To  clear  up  the  diagnosis  attention  should  be  paid  to 
the  following  points  : — 

The  presence  of  unequal,  rigid  or  Argyll-Robertson 
pupils,  even  if  transitory,  means  G.P.I. 

The  Remissions. — In  paralytics  the  remissions  are  often 
incomplete,  that  is  to  say,  they  take  the  form  of  diminution 
of  the  stupor  to  the  extent  that  the  patient  will  reply 
to  questions,  but  after  a  pause  and  in  a  word  or  two. 
And  these  partial  remissions  are  the  observer's  oppor- 
tunity to  examine  the  patient's  intellectual,  volitional, 
and  emotional  signs  and  reactions.  Complete  lack  of 
autocriticism,  the  presence  of  apathy,  or  signs  of  latent 
euphoria,  indicate  G.P.I.  The  lucid  intervals  in  amentia 
attonita  are  much  more  complete,  much  shorter,  and 
more  frequent  and  they  do  not  exhibit  the  above  men- 
tioned signs.  A  Wassermann  test  of  the  cerebro-spinal 
fluid  should  always  be  done  in  doubtful  cases. 

From  Epileptic  Stupor  : — 

The  transitory  mild  attacks  of  stupor  in  G.P.I,  are 
easily  distinguished  from  epileptic  stupor.  The  epileptic 
is  much  more  stupefied  and  inaccessible  ;  in  his  less  clouded 
phases  he  manifests  the  slow  stumbling  mentation 
of  his  class  instead  of  paralytic  divertibility,  futility, 
euphoria,  etc.  The  prolonged  varieties  of  paralytic 
stupor  of  amential  type  can  be  distinguished  from  epilepsy 
upon  similar  lines  to  those  suggested  for  the  distinction 
of  amentia  from  epilepsy  (p.  92). 

7.  "  MANIACAL  STUPOR  " 

This  condition  is  not  very  common.  It  is  regarded  by 
some,  notably  Krsepelin,  as  a  form  of  maniacal  depressive 
insanity  which  exhibits  a  mixed  clinical  picture  composed 
of  the  symptoms  of  mania  and  melancholia  at  the  same 
time.     It  is  said  to  replace  mania  or  melancholia  occa- 


96  COMMON  TYPES   OF  INSANITY 

sionally  in  a  series  of  manic-depressive  attacks.  Be  this 
as  it  may,  there  is  no  doubt  that  in  its  symptomatology 
it  also  bears  some  resemblance  to  an  amential  condition. 
There  is  neither  the  exuberance  of  mania  nor  the  misery  of 
melancholia.  It  should  also  be  borne  in  mind  that  re- 
currence in  more  or  less  isolated  attacks  is  not  by  any 
means  confined  to  the  manic-depressive  psychoses. 

Symptoms 

1.  Short  periods  of  more  or  less  immobility  broken  by 
restless  disconnected  action,  tricks,  and  silly,  but  not 
motiveless,  conduct. 

2.  Mutism,  but  for  occasional  unintelligible  muttering 
and  irrelevant  or  stupid  remarks.  Some  cases  are  noisy, 
garrulous,  and  maniacal  at  times. 

3.  A  moderate  degree  of  imperception,  with  inability 
to  combine  percepts,  confusion  and  disorientation ;  but 
good  comprehension  of  simple  conversation.  Illusions 
of  identity  are  common.  The  patient  is  easily  accessible, 
but  entirely  misunderstands  his  surroundings  and  his 
relationship  to  them. 

4.  A  variable,  rapidly  changing  mood,  manifesting  a 
prevailing  tone  of  sly  cheerful  facetiousness.  Transitory 
apprehension,  anger  and  superficial  misery  occur. 

5.  Divertibility,  so  far  as  the  confusion  permits. 

6.  Hallucinations  are  rare  and  when  present  probably 
indicative  of  exhaustion. 

Prognosis 

Recovery,  sometimes  after  a  year's  duration,  is  the  rule. 

Treatment 

The  treatment  should  be  on  general  lines.  Nothing 
special  is  indicated. 


"MANIACAL  STUPOR"  97 

Differential  Diagnosis 

Circular  stupor  is  excluded  by  the  absence  of  genuine 
persistent  depression  of  spirits  and  mental  pain ;  kata- 
tonic  stupor  by  the  absence  of  katatonia  ;  amentia 
attonita  by  the  presence  of  ideation,  motor  symptoms 
and  emotional  states,  and  by  the  absence  of  inaccessibility. 

Simple  stupor  in  dementia  praecox  approaches  somewhat 
nearer  to  the  clinical  picture  of  "  maniacal  stupor."  The 
main  distinctions  are  the  presence  in  the  latter  of  con- 
fusion concerning  external  impressions,  and  of  disorienta- 
tion, divertibility,  and  sincere,  if  changeable,  states  of 
emotion  ;  and  the  absence  of  motiveless  acts  (which  are 
not  infrequently  to  be  observed  in  the  hebephrenic)  and 
the  self-puzzled  state  already  noticed. 

The  distinctions  from  epileptic  stupor  are  too  apparent 
to  call  for  comment. 

Maniacal  stupor  is  distinguished  from  paralytic  stupor 
or  confusion,  by  the  presence  of  more  active  mentation, 
livelier  attention,  interest,  and  emotional  states,  as 
well  as  by  the  absence  of  paralytic  delusions  and  physical 
signs.  The  marked  prolonged  types  of  stupor  in  paraly- 
tics are  not  in  the  least  like  "  maniacal  stupor." 


E.M.D. 


CHAPTER  V 

STATES  OF  MENTAL  ENFEEBLEMENT 

Mental  enfeeblement  is  a  feature  of  a  large  number  of 
mental  disorders,  and  is  present  to  some  extent  in  many 
of  those  already  described.  In  some  of  these  it  is  only  of 
academic  interest  to  distinguish  the  varieties  of  impair- 
ment, but  in  others  its  special  features  are  of  diagnostic 
importance.  Then  there  are  cases  in  which  weak-minded- 
ness may  constitute  almost  the  entire  course,  e.  g.,  im- 
becility and  some  gross  cerebral  lesions. 

1.  DEMENTIA  PARALYTICA 

Progressive  deterioration  from  the  onset,  mental  and 
physical,  is  characteristic  of  G.P.I.  The  dissolution  of 
mental  functions  is  in  inverse  order  to  their  acquisition. 
In  some  varieties  of  the  disease  dementia  is  the  most  con- 
spicuous mental  feature  throughout ;  probably  this  is  the 
commonest  type.  The  final  state  in  all  cases  that  weather 
the  dangerous  crises,  is  a  condition  of  bedridden  marasmus 
with  almost  complete  abolition  of  mentation,  only  a  few 
of  the  lower  instincts  such  as  those  of  eating  and  defence 
persisting. 

Symptoms 

The  following  are  the  chief  symptoms  of  a  moderate 
degree  of  paralytic  dementia  : — 

1.  Amnesia,  chiefly  for  time  and  dates,  often  accom- 

98 


DEMENTIA  PARALYTICA  99 

panied  by  inability  to  do  simple  calculations  formerly 
accomplished  with  ease. 

2.  Absence  of  autocriticism. 

3.  Impaired  passive  attention  and  slow  perception  : — 
Imperception  in  later  stages  or  confusional  episodes. 

4.  Poverty  of  ideas  (except  in  megalomania)  and  slow 
ideation.  Loss  of  the  power  of  forming  concepts  or  com- 
bining percepts,  so  that  only  an  imperfect  idea  of  the 
general  situation  is  present,  and  not  uncommonly,  dis- 
orientation. 

5.  A  mood  of  apathy  and  lack  of  natural  interest  in  the 
immediate  surroundings.  The  emotional  reaction  to 
stimuli  may  be  practically  absent,  or  may  manifest  a 
childish  superficial  exaggeration. 

6.  Feeble  volition,  with  divertibility  in  mood  and 
conduct  to  a  greater  extent  than  in  any  other  form  of 
dementia. 

7.  Good,  if  slow,  comprehension  of  conversation. 

8.  Some  indications  of  euphoria,  and  perhaps 
persistence  of  some  characteristic  delusion  or  of  other 
phases  of  the  malady  such  as  those  already  described. 

9.  Irrational  conduct. 

10.  Alterations  in  the  individual  character. 

11.  Physical  signs  of  G.P.I.,  e.g.  Fine  tremors  of 
lips,  tongue  and  hands,  and  sometimes  of  lower  limbs, 
trombone  movements  of  tongue  on  protrusion,  slurred  speech 
with  syllable  stumbling  ;  pupillary  changes,  i.  e.,  rigidity, 
Argyll-Robertson,  myosis,  or  inequality ;  amimia  of  lower 
facial  area,  increased  knee-jerks  with  floppy  return,  or  their 
absence  ;  Rhomberg's  sign  ;  unsteady  spastic  or  tabetic 
gait ;  bladder  or  rectal  insufficiency  ;  dysphagia  ;  optic 
atrophy  ;  paresis  of  groups  of  muscles,  epileptiform  fits, 
etc. 

Any  or  all  of  these  may  be  present,  the  more  common 
and  those  of  most  diagnostic  significance  are  printed  in 


100  COMMON  TYPES  OF  INSANITY 

italics.     It  is  important  to  remember  that  most  of  these 
physical  signs  are  subject  to  remission. 

Differential  Diagnosis 

The  diagnosis  from  other  forms  of  mental  dissolution 
will  be  discussed  later.  It  is  perhaps  as  well  here  to 
suggest  distinctive  points  between  early  G.P.I,  and  the 
ever  increasingly  common  neurosis,  neurasthenia.1 

The  budding  paralytic  is  preoccupied  and  rather 
depressed  ;  the  quality  of  his  work  deteriorates  ;  his 
power  of  application  weakens  ;  he  is  soon  fatigued,  and 
he  grows  moody  and  forgetful ;  he  may  also  have  hypo- 
chondriacal notions. 

All  these  symptoms  occur  in  neurasthenia.  The  fol- 
lowing are  some  of  the  points  of  distinction  : — 

In  neurasthenia  these  shortcomings  meet  with  exag- 
gerated notice  and  anxiety  on  the  part  of  their  subjects. 
If  the  paralytic  observes  them  at  all,  he  is  not  in  the 
least  put  out  thereby  ;  and  if  they  are  pointed  out  to  him, 
he  passes  them  off  with  an  excuse.  In  a  word,  the 
paralytic's  autocriticism  is  defective.  His  depression 
is  not  in  part  due  to  self-observation,  but  to  ccensesthetic 
disorder. 

The  neurasthenic's  passive  attention  and  observation 
are  morbidly  acute  ;  the  paralytic's  blunted,  his  percep- 
tion slow.  Hypochondriacal  ideas  in  neurasthenia  are 
productive  of  considerable  dejection  or  agitation ;  in 
G.P.I,  only  very  shallow  emotion  appears  to  be  felt,  and 
the  ideas  may  manifest  hintings  of  a  coming  euphoria 
or  a  grossness  entirely  at  variance  with  the  fancies  of 

1  The  term  Neurasthenia  is  used  throughout  this  work,  unless 
otherwise  stated,  to  include  the  true  neurasthenic  asthenia  as  well 
as  the  anxiety  neurosis.  In  the  vast  majority  of  cases  they 
do  not  occur  as  separate  entities. 


DEMENTIA  PRECOX  101 

the    neurosis.     Indications   of   moral   degradation   and 
change  of  character  at  once  exclude  neurasthenia. 

Sudden  conspicuous  transitory  amnesia  indicates  G.P.I, 
or  some  psychosis.  Some  early  paralytics,  however, 
especially  those  belonging  to  the  educated  classes,  even 
when  euphoric,  appear  to  suffer  from  transitory  periods  of 
clear  insight.  The  condition  in  which  they  are,  though 
even  then  not  fully  understood,  fills  them  with  a  transi- 
tory blind  horror  and  despair.  These  temporary  returns 
of  the  power  of  autocriticism  account  for  the  suicides 
amongst  early  G.P.'s. 


2.  DEMENTIA  PRECOX 

Several  phases  of  this  disease  have  already  been 
considered,  and  incidentally  the  features  of  the  mental 
impairment  mentioned. 

Here  the  latter  will  be  briefly  grouped  together.  The 
reader  is  recommended  to  refer  back  to  page  64  for  quota- 
tions of  the  essential  underlying  signs  of  the  malady. 
The  final  stage  is  the  automatic  dement  of  asylums — 
stereotyped,  silent  or  talking  unintelligible  rubbish,  self- 
neglectful,  motiveless,  without  ideas,  and  almost  without 
instincts,  except  that  for  food ;  and  yet  not  disorient- 
ated, not  affected  in  comprehension  of  conversation,  nor 
amnesic. 

Symptoms 

1.  Complete  apathy,  with  loss  of  emotional  reaction, 
interest  and  motives  for  action. 

2.  Poverty  of  ideas. 

3.  Greatly  impaired  judgment,  instanced  by  ridiculous 
transitory  or  more  or  less  fixed  delusions,  which  are 
completely  barren  of  results. 


s 

102  COMMON  TYPES   OF  INSANITY 

4.  Often,  persisting  hallucinations  or  pseudo-hallucina- 
tions. 

5.  Motiveless  conduct. 

6.  Remnants  of  earlier  phases,  e.  g.,  periodical  attacks 
of  motor  excitement. 

7.  Some  katatonic  symptoms. 

8.  Unimpaired  comprehension  and  knowledge  of  time 
and  place,  good  perception  and  memory,  so  far  as  the 
complete  indifference  to  surroundings  permits. 

Prognosis  and  Incidence 

The  type  of  adolescent  most  liable  to  develop  dementia 
prsecox  is  the  reserved,  seclusive,  and  self-contained  ;  and 
when  the  psychosis  develops  in  such  individuals  the  out- 
look is  hopeless.  Initial  acute  manifestations  occurring 
in  persons  of  normal  temperament  are  said  to  result  in 
complete  recovery,  but  many  of  the  cases  of  this  variety 
described,  are  obviously  amential  attacks  with  katatonic 
symptoms,  or  other  psychoses.  It  is  probable  that 
normally  vivacious,  communicative  and  gregarious  persons 

areimmunefromthedisease' 

Differential  Diagnosis 

The  distinctions  from  dementia  paralytica  are  too 
apparent  to  call  for  enumeration. 


3.  SENILE  DEMENTIA 

The  majority  of  old  people  manifest  some  degree  of 
mental  impairment,  but  true  senile  dementia  does  not  by 
any  means  invariably  supervene.  It  is  probable  that 
its  incidence  implies  some  inherent  or  acquired  defect  in 
the  cerebral  mechanism.     Senile  dementia  is  regarded 


SENILE   DEMENTIA  103 

as  in  part  due  to  primary  degenerative  cortical  changes 
(abiotrophy)  in  part  due  to  secondary  effects  of  cerebral 
arterio-sclerosis  (arteriopathy ) . 

As  previously  noted,, these  changes  are  associated  with 
attacks  of  excitement,  depression,  etc.,  as  well  as  pro- 
ductive of  dementia. 


Symptoms 

1.  Amnesia,  chiefly  loss  of  power  to  retain  recent 
impressions. 

2.  Impaired  power  of  attention. 

3.  Volitional  feebleness  and  divertibihty. 

4.  Emotional  instability,  usually  with  excessive  re- 
action. The  prevailing  tone  may  be  apathy,  suspicion, 
resentment,  depression,  or  exaltation. 

5.  Circumscribed  egocentric  childish  ideation,  with 
puerile  interests  and  amusements.  Sometimes  a  tendency 
to  ideational  inertia  (vide  Glossary). 

6.  Relatively  active  mentation  within  its  horizon  and 
when  stimulated  by  external  agents,  with  good  com- 
prehension of  simple  conversation. 

7.  Impaired  perception  ;  inability  to  associate  per- 
cepts ;    and  disorientation. 

8.  Physical  signs  of  senility. 

9.  Sometimes  focal  symptoms,  e.  g.  transitory  aphasias, 
paraphasias,  fits,  thromboses,  etc. 


Prognosis 

This  is  of  course  hopeless.  The  termination  is  a 
bedridden  dement,  helpless,  and  almost  mindless.  These 
cases  live  almost  indefinitely  in  asylums,  which,  incident- 
ally, are  most  unsuitable  places  for  them. 


104  COMMON  TYPES  OF  INSANITY 

Treatment 

Nocturnal  restlessness  is  the  rule  in  these  cases,  and  is 
best  combated  by  purgation,  chloralainide  grains  15  to 
20,  or  by  paraldehyde  in  doses  of  1  or  2  drachms 
at  night.  The  patients  are  apt  to  wander  about,  so  care 
should  be  taken  that  they  do  not  fall  down,  fall  into  a 
fire,  or  interfere  with  others,  and  consequently  be  pushed 
over.  Not  a  few  fractures  of  the  femur  have  resulted 
from  this  in  asylums.  They  should  sleep  on  low  bed- 
steads. 

Differential  Diagnosis 

Senile  dementia  cannot  be  mistaken  for  either  of  the 
preceding  forms  of  dementia.  Distinctions  from  subse- 
quent varieties  will  be  mentioned  under  their  respective 
headings. 

4.  ARTERIOSCLEROTIC  DEMENTIA 

This  form  of  enfeeblement  as  the  name  implies  is  due 
to  cerebral  arterio-sclerosis.  For  the  causes  of  the 
latter  the  reader  is  referred  to  other  works.  The  clinical 
picture  resembles  in  a  general  way  that  of  senile  dementia. 
which  indeed  is  in  part  due  to  the  same  cause. 

The  main  points  of  distinction  are  as  follows  : — 

In  Arteriosclerotic  Dementia  :— 

1.  The  amnesia  is  general,  and  not  particularly  for 
recent  events. 

2.  A  more  vacant  mood  is  present,  without  undue 
emotional  reaction,  or  senile  changes  in  character  ,e.  g., 
suspicion,  egotism,  cruelty. 

3.  Intellectual  activity  is  less,  but  also  less  circum- 
scribed, f 


SYPHILITIC  DEMENTIA  105 

4.  Delusions,  marked  emotional  disturbances,  and 
confusion,  are  absent. 

5.  The  conduct  is  not  childish  and  silly,  but  sensible 
and  orderly,  so  far  as  the  dementia  permits. 

6.  As  a  rule  the  patient  is  not  physically  senile. 

7.  A  sense  of  illness  is  sometimes  present. 
Arterio-sclerotic    dementia    bears    some    likeness    to 

Dementia  Paralytica.  The  similarity  is  increased  by 
the  incidence  or  history  of  focal  signs,  pareses,  etc.,  and 
transitory  unconsciousness. 

The  chief  distinctions  are  as  follows  : — 

In  Arteriosclerotic  Dementia  : — 

1.  The  amnesia  is  mainly  for  remote  and  general 
events,  not  for  recent,  nor  particularly  marked  concerning 
times  and  dates. 

2.  Autocriticism  is  not  abolished,  a  sense  of  illness 
frequently  being  present. 

3.  Delusions  are  absent. 

4.  The  conduct  is  logical  and  orderly. 

5.  There  is  often  a  marked  tendency  to  rapid  mental 
fatigue,  e.g.,  in  the  course  of  conversation.  Ideational 
inertia  sometimes  occurs. 

6.  The  typical  physical  signs  of  G.P.I,  are  absent 
(vide  p.  99). 


5.  SYPHILITIC  DEMENTIA 

Gross  cerebral  syphilis  may  produce  clinical  pictures 
resembling  or  identical  with  that  described  as  arterio- 
sclerotic dementia,  and  doubtless  arising  from  the  same 
proximate  cause.  Cerebral  gummata  occasionally  result 
in  conditions  analogous  to  those  instanced  on  pages  42-45. 

But  the  most  frequent  result  of  cerebral  syphilis  is 
a  simple  dementia  with  amnesia,  intellectual  and  voli- 


106  COMMON  TYPES  OF  INSANITY 

tional  inertia,  and  slight  emotional  depression.  What- 
ever the  mental  symptoms  may  be,  physical  signs  of  gross 
cerebral  disease  co-exist. 

Some  cases  of  diffuse  gross  syphilitic  brain  disease 
involving  meninges,  vessels,  etc.,  in  their  clinical  mani- 
festations closely  resemble  G.P.I.  The  distinctions  be- 
tween the  two  conditions  are  given  below.  Not  a  few 
of  these  cases,  however,  are  practically  indistinguishable 
in  life  ;  the  diagnosis  is  only  cleared  up  on  the  post- 
mortem table.  This  is  no  matter  for  surprise,  when  one 
reflects  that  the  cause  of  the  two  affections  is  the  same  ; 
the  setiological  difference  being  merely  one  of  localization 
and  relative  coarseness  of  lesions. 

When  present  the  following  distinctions  from  dementia 
paralytica  incidentally  indicate  the  type  of  Syphilitic 
Dementia  in  general : — 

1.  The  onset  is  usually  relatively  sudden,  within  five 
years  of  infection. 

2.  The  amnesia  in  view  of  the  prominent  physical  signs 
is  less  marked. 

3.  Ideation  and  perception  are  more  active  in  propor- 
tion to  the  physical  signs. 

4.  Autocriticism  is  not  destroyed — a  definite  sense  of 
illness  being  present. 

5.  Orientation  in  time  and  space  is  not  lost. 

6.  Euphoria  and  expansive  delusions  are  not  very 
common. 

7.  The  conduct  is  not  irrational,  nor  is  there  any 
marked  change  in  character  or  personality. 

8.  Episodic  excitement,  confusion,  etc.,  is  sudden  and 
pronounced. 

9.  Physical  signs  of  coarse  cerebral  lesions  are  almost 
always  present,  and  occasionally  tertiary  symptoms  in 
other  parts. 

10.  The  remissions  in  mental  symptoms  and  physical 


EPILEPTIC  FEEBLE-MINDEDNESS         107 

signs  which  are  sometimes  seen  in  G.P.I,  almost  invariably 
occur  in  syphilitic  dementia. 

Prognosis 

On  the  whole  the  outlook  is  unfavourable.  The 
majority  of  cases  appear  to  be  unaffected  by  mercurials 
and  iodides. 

Treatment 

Anti-syphilitic  treatment  should  of  course  be  tried, 
intra-muscular  injections,  inunctions,  or  intrathecal 
medications,  as  well  as  salvarsan. 


6.  EPILEPTIC  FEEBLE- MINDEDNESS 

Chronic  epilepsy  tends  to  dementia,  although  in  some 
cases  the  enfeeblement  is  negligible.  The  more  frequent 
the  fits,  the  deeper  the  dementia  ;  the  younger  the  patient 
at  the  onset  of  the  fits  the  more  rapid  is  the  mental 
degeneration.  Some  cases  reach  a  very  high  degree 
of  enfeeblement  in  which  almost  all  mentation  is  destroyed. 

The  type  of  dementia  is  set  out  in  the  following 

Symptoms 

1.  Slow,  clumsy  thought,  limited  to  the  patient's 
immediate  environment.     Poverty  in  ideas. 

2.  Retardation  in  comprehension  of  simple  remarks 
resulting  in  a  slow  reaction  to  questions  in  spite  of 
excellent  attention. 

3.  Amnesia,  chiefly  for  remote  events  and  general 
incidents. 

4.  Collectedness  and  clearness  about  surroundings  and 
time. 


108  COMMON  TYPES   OF  INSANITY 

5.  Slow,  childish.,  but  formal  and  unnecessarily  detailed 
speech  exhibiting  a  Terr  limited  vocabulary. 

6.  A  mood  which  is  usually  described  as  "  wound  up." 
i.  £..  the  patient  is  prone  to  emotional  outbursts  upon 
slight  provocation. 

7.  Slow  awkward  movements. 

8.  Orderly  and  even  fastidious  conduct,  apart  from 
"'■'  equivalents." 

9.  Understanding  of  the  illness  from  which  the  patient 
suffers,  but  a  groundlessly  optimistic  view  of  it. 

10.  The  occurrence  of  epileptic  fits  and  "  equiva- 
lents." 

11.  A  serious  character  or  temperament  in  which 
selfishness,  excessive  self-esteem,  sensitiveness,  obstinacy, 
perseverance  and  power  of  application,  are  mingled  with 
an  external  piety  and  deep  vindictiveness. 

Epileptics  are  said  sometimes  to  lack  all  altruism  and 
to  be  viciously  cruel,  on  the  ground  that  they  occasionally 
commit  brutal  crimes,  etc. 

This  statement  is  hardly  fair,  the  truth  of  the  matter 
being  that  nine-tenths  of  the  crimes  so  committed  are  the 
result  of  some  form  of  pathological  explosion. 

Treatment 

In  dealing  with  epileptics  in  asylums,  that  is  to  say,  with 
those  whose  conduct  or  dementia  has  brought  them  into 
conflict  with  their  environment  and  hence  caused  them 
to  be  labelled  in  a  separate  class  as  insane  epileptics, 
each  case  must  be  studied  and  considered  on  its  own 
merits.  The  indiscriminate  use  of  bromides  is  to  be 
condemned.  Cases  too  deeply  demented  ever  to  be  fit 
for  discharge  are  better  without  bromides  altogether, 
occasional  fits  being  preferable  to  continual  wretchedness 
broken  by  episodes  of  violence  and  excitement. 


EPILEPTIC  FEEBLE-MINDEDNESS         109 

Some  cases  do  well  on  hyoscine  hydrobromide  by  the 
mouth,  some  on  chloral  hydrate,  the  majority  on  nothing 
at  all,  except  regularly  administered  aperients. 

Limitation  of  diet  in  these  cases  merely  produces 
resentment. 

If  an  epileptic  suffers  from  continual  fits  which  tend 
to  result  in  dangerous  falls  or  to  incapacitate  him  for 
occupation,  he  must  have  bromides,  and  perhaps  the 
best  combination  is  the  triple  salts  with  arsenic  and  nux 
vomica. 

As  mentioned  before,  tact,  kindliness,  unpatronizing 
sympathy  and  consideration,  of  course  combined  with 
firmness,  are  essential  in  managing  insane  epileptics, 
and  for  that  matter,  sane  ones  as  well.  Never  treat  an 
epileptic  with  condescension  or  nonchalance,  but  as  an 
afflicted  equal. 

Make  a  friend  of  him,  he  will  remain  one  to  the  end  ; 
and  in  many  cases  apart  from  his  equivalents  (and  even 
to  some  extent  in  them)  he  will  be  as  wax  in  your  hands. 
Epileptics  are  excellent  readers  of  character,  so  eschew 
all  mere  show  of  sympathy  and  kindness  or  you  will  be 
detected  at  once  and  distrusted. 

Avoid  even  well-meant  deception,  or  the  patients' 
confidence  may  be  forfeited  for  ever.  In  a  word,  the 
whole  secret  of  managing  epileptics,  and  indeed  all  com- 
paratively lucid  mental  cases,  is  to  feel  as  well  as  appear 
a  brother  to  them.  If  a  man  cannot  achieve  this  attitude 
he  had  better  not  take  up  the  study  and  treatment  of  the 
insane. 

Chloral  hydrate  grains  30,  per  rectum,  is  useful  in  recur- 
ring fits  (i.  e.,  series).  Actual  status  epilepticus,  in  which 
the  patient  has  a  series  of  fits  without  an  interval  of 
consciousness  between,  calls  for  chloroform  inhalation  in 
addition.  All  epileptic  equivalents  should  be  treated 
by  aperients. 


110  COMMON  TYPES  OF  INSANITY 

Differential  Diagnosis 

1.  From  Dementia  Paralytica  : — 
Present  in  epilepsy — absent  in  G.P.I.  : 

(1)  Limitation  of  ideas  to  the  immediate  environment, 

with 

(2)  Good  attention  and  power  of  mental  application 

within  this  circumscribed  horizon. 

(3)  Clear  understanding  of  the  general  situation. 

(4)  Autocriticism  and  a  sense  of  illness. 

(5)  Amnesia  for  remote  and  general  events. 

(6)  The  epileptic  temperament. 
Present  in  G.P.I. — absent  in  epilepsy  : 

(1)  Apathy,    with    or    without    a    basic    euphoria; 

feeble  emotional  re-action. 

(2)  Impaired  volition  with  childish  divertibility. 

(3)  Irrational   conduct,    even   apart   from   episodic 

disturbances. 

(4)  Relatively  rapid  comprehension  and  mentation 

generally. 

(5)  Amnesia  mainly  for  times  and  dates. 

(6)  Physical  signs. 

The  points  of  distinction  suggested,  are  those  between 
only  a  moderate  degree  of  paralytic  dementia  and  epileptic 
dementia.     Advanced  G.P.I,  cannot  be  missed. 

2.  From  Senile  Dementia  : — 

The  following  points  in  senile  dementia  are  the  main 
diagnostic  features  : 

The  type  of  amnesia,  the  impaired  attention,  volitional 
feebleness,  defective  perception,  disorientation,  in  con- 
junction with  relatively  rapid  comprehension  and  menta- 
tion generally. 

3.  From  Dementia  Prjscox  : — 
Present  in  epilepsy  : 

(1)  Effective  but  slow  mentation  within  a  limited 


EPILEPTIC   FEEBLE-MINDEDNESS         111 

horizon.  This  is  productive  of  useful  association 
of  ideas  and  results  in  motives  and  subsequent 
action. 

(2)  "  Wound  up  "  mood. 

(3)  Logical  conduct. 

(4)  Rational    but    childish    speech,     with    limited 

vocabulary. 

(5)  Epileptic  character. 

(6)  Amnesia. 

(7)  Sense  of  illness. 

(8)  "  Equivalents  "  or  periodical  fits. 
Present  in  dementia  praecox  : 

(1)  Quicker  but  perverted  ineffective  and  valueless 

mentation  of  wider  scope.  This  is  sterile, 
resulting  in  nothing  useful. 

(2)  Complete  apathy, 

(3)  Motiveless  conduct,  with  some  katatonic  signs. 

(4)  Pedantic  absurd  talk,  full  of  long  words,  neo- 

logisms, and  meaningless  phrases. 

(5)  No  character. 

(6)  Attacks  of  characteristic  type,  which  have  been 

outlined.  Cases  of  dementia  prsecox  not  infre- 
quently have  one  or  two  isolated  fits  in  the  course 
of  the  disease. 

4.  From  Arteriosclerotic  Dementia  : — 

The  presence  in  epilepsy  and  the  absence  in  arterial 
dementia  of  the  following  features,  is  important  in  the 
differentiation  ;  sustained  power  of  attention  and  intellec- 
tual application,  the  "  wound  up  "  mood,  the  epileptic 
character,  clumsy  retardation  of  thought,  speech,  and 
movements,  periodicity  in  fits,  and  the  occurrence  of 
equivalents. 

5.  From  Syphilitic  Dementia  : — 

In   syphilitic   dementia   there   are   remissions   in   the 


112  COMMON  TYPES  OF  INSANITY 

dementia,  and  there  are  physical  signs  ;  there  is  no  retard- 
ation of  mentation  of  epileptic  type,  no  epileptic  mood 
or  character,  and  no  periodicity  in  fits  or  episodic  mental 
disturbances. 

7.  ALCOHOLIC  DEMENTIA 

All  alcoholics  do  not  become  definitely  weak-minded, 
any  more  than  all  old  people  dements.  Probably  some 
cerebral  factor  of  inherent  character  is  also  necessary. 
Some  of  the  features  of  alcoholic  enfeeblement  have 
already  been  referred  to. 

Symptoms 

1.  Semi-humorous,  semi-irritable  mood. 

2.  Amnesia,  mainly  for  recent  events.  This  may  be 
of  high  degree  so  that  the  patient  forgets  what  he  has  been 
told  a  few  minutes  previously. 

3.  Loss  of  higher  moral  control  resulting  in  selfishness, 
lying  and  brutalization  of  conduct. 

4.  Impaired  power  of  attention  ;  poverty  of  thought 
and  interests  and  limitation  of  intellectual  horizon. 

5.  Defective  judgment,  shown  sometimes  by  ideas  of 
persecution,  grandeur,  jealousy  of  conjugal  fidelity, 
etc.,  all  intrinsically  possible  however  improbable. 

6.  Volitional  feebleness  and  divertibility  in  conduct, 
except  when  the  patient  is  under  the  influence  of  an 
immediate  dose  of  alcohol  and  hence  enraged  or  excited. 

7.  Physical  signs  of  chronic  alcoholism  (vide  pp.  34  and 
37),  including  the  alcoholic  facies. 

Differential  Diagnosis 

1.  From  Dementia  Paralytica  : — 
Stress  should  be  laid  upon  the  following  symptoms 
in  G.P.I.  : 

Apathetic  mood,  amnesia  mainly  for  time  and  dates, 


ALCOHOLIC  DEMENTIA  113 

inability  to  do  simple  calculations,  absence  of  auto- 
criticism  and  of  understanding  of  the  general  situation. 
Impaired  perception,  irrational  conduct,  and  physical 
signs  (see  pp.  37  and  99). 

2.  From  Senile  Dementia  : — 

An  old  alcoholic  will  present  mingled  symptoms  of  the 
two  conditions.  A  middle-aged  alcoholic  will  be  dis- 
tinguished by  his  age.  The  main  difference  in  the 
type  of  dementia  can  be  seen  from  the  detailed  symptoms 
of  the  two  conditions,  but  are  of  academic  interest  only. 

3.  From  Arterial  Dementia  : — 

The  arterial  dement  suffers  from  general  amnesia  ; 
in  character  he  is  more  or  less  negative,  and  in  mood 
indifferent ;  he  is  more  passive  and  anergic,  and  may 
present  ideational  inertia  and  focal  signs.  The  alco- 
holic's mnemonic  impairment  is  mainly  for  recent  events, 
his  mood  jocularly  surly  or  irritable;  in  character  he  is  a 
feeble  sort  of  blackguard  ;  and  he  manifests  alcoholic 
physical  signs  and  sometimes  delusions  and  auditory 
hallucinations. 

Naturally  the  two  conditions  may  co-exist. 

4.  From  Syphilitic  Dementia  : — 

Syphilitic  dementia  is  mainly  distinguished  from  alco- 
holic by  the  presence  of  focal  signs,  by  the  remissions, 
the  general  amnesia,  and  the  absence  of  the  alcoholic 
mood  and  moral  degeneration. 

Moreover,  the  former  class  of  patient  has  the  indescrib- 
able appearance  peculiar  to  gross  cerebral  disease — an 
appearance  and  demeanour  that  frequently  enable  one 
to  say  at  once  that  some  organic  gross  lesion  is  present 
long  before  any  actual  diagnosis  is  arrived  at.  There  is  a 
general  and  marked  lack  of  alertness,  an  aspect  of  oppres- 
sion and  helplessness  peculiar  to  these  sufferers. 

e.m.d.  8 


114  COMMON  TYPES   OF  INSANITY 

Dementia  prsecox  and  epileptic  dementia  cannot  be 
mistaken  for  the  alcoholic  variety  of  enfeeblement, 
though,  of  course,  the  two  latter  may  co-exist.  When 
this  is  the  case,  the  result  may  be  one  of  the  worst  types 
of  insane  criminal. 

The  whole  list  of  signs  peculiar  to  epileptic  dementia, 
given  on  page  107  except  No.  4,  are  absent  in  pure  alco- 
holic dementia  ;  and  in  epilepsy  are  absent  the  alcoholic 
semi-humorous  mood.,  impaired  attention,  volitional 
weakness,  and  the  physical  signs. 

8.  APOPLECTIC  DEMENTIA 

There  is  no  difficulty  in  the  diagnosis  of  this  condition. 
The  usual  features  are  :  hemiplegia  ;  aphasias  ;  childish, 
extreme  emotionalism  ;  persistence  of  former  motor 
impulses  ;  without  disorderly  conduct,  disorientation,  or 
confusion  about  the  general  situation. 

9.  IMBECILITY 

Imbecility  as  described  here  is  regarded  as  the  final 
expression  of  the  "  degeneration  "  of  the  stock.  It  is  a 
spontaneous  arrest  of  mental  development  due  to  inherent 
factors  and  is  to  be  distinguished  from  congenital  idiocy 
(due  to  fcetal  or  infantile  cerebropathies)  which  is  an 
acquired  pathological  condition.  Cerebropathic  idiots 
manifest  some  signs  of  past  gross  cerebral  lesions,  e.  g., 
paralysis  or  epilepsy,  and  their  psychological  characters 
are  essentially  negative. 

Symptoms  of  Imbecility 

1.  Limited  intelligence  and  circumscribed  intellectual 
horizon  ;  absence  of  general  knowledge,  general  ideas, 
concepts  (e.  g.,  abstractions,  such  as,  truth,  evil),  and  of 
imagination. 


IMBECILITY  115 

2.  Carelessness  of  the  future,  absence  of  plans  or  hopes. 

3.  Absence  of  critical  faculty,  resulting  in  misplaced 
excessive  credulity  and  distrust. 

4.  Excellent  passive  attention  and  rapid  perception, 
but  feeble  voluntary  attention  easily  distracted  by  chance 
percepts. 

5.  Good  memory  for  facts  ;  that  is  to  say,  simple  things 
that  happen  to  have  made  an  impression. 

6.  Active  emotional  states,  with  great  play  of  facial 
expression  and  excessive  emotional  reactions. 

7.  Impertinence  and  absence  of  modesty. 

8.  Limited  vocabulary,  and  usually,  defective  articu- 
lation. 

9.  A  childish  character,  in  which  vanity,  fickleness, 
jealousy,  cruelty,  absence  of  altruism,  pretence  and 
mimicry,  play  important  roles  ;  together  with  inability 
to  apply  and  a  tendency  to  all  forms  of  immorality. 

Prognosis 

Facts  can  be  instilled  into  an  imbecile,  but  he  is  in- 
capable of  applying  them  to  his  life.  As  Tanzi  has  it, 
imbeciles  can  be  instructed  but  not  educated. 

The  vast  majority  of  imbeciles  are  at  large.  These 
anomalous  persons  are  prone  to  acquire  psychoses, 
just  as  are  paranoiacs,  and  the  disciples  of  the  latter 
consist  for  the  most  part  of  the  former. 

Differential  Diagnosis 

It  is  only  necessary  to  suggest  distinctions  between 
imbecility  and  the  three  following  psychoses  : 

1.  Diagnosis  from  Epileptic  Dementia  : — 

In  epilepsy,  comprehension  and  mental  action  generally 
is   retarded ;    in  imbecility,   both  are  rapid.     Memory 


116  COMMON  TYPES   OF  INSANITY 

is  often  impaired  in  epilepsy,  excellent  in  imbecility. 
In  the  former  there  is  good  power  of  voluntary  attention 
and  of  application  ;  in  the  latter  the  reverse  is  the  case. 
Finally  a  sense  of  illness  exists  in  epileptics,  whereas 
the  imbecile  is  wrapped  up  in  a  very  perfect  self-satisfac- 
tion. 

2.  Diagnosis  from  Dementia  Prjscox  : — 

In  dementia  prsecox,  general  knowledge  and  ideas  are 
present  but  useless  ;  the  vocabulary  is  anything  but 
childishly  limited ;  the  mood  is  apathetic  and  the 
emotional  reaction  defective  or  nil. 

Some  imbeciles,  however,  develop  dementia  prsecox 
at  an  early  age,  and  in  a  year  or  so  become  extremely 
demented. 

3.  Diagnosis  from  Chronic  Hypomania  (vide  infra) : — 

The  subjects  of  constitutional  excitement  of  slight 
degree  conduct  their  lives  very  much  after  the  fashion  of 
high-grade  imbeciles.  They  not  infrequently  squander 
money,  disgrace  their  friends,  come  into  conflict  with 
the  law,  etc.  But  psychologically  the  two  conditions 
are  opposed.  The  hypomaniac  is  full  of  changing  schemes 
and  plans  ;  he  has  quite  fair  general  knowledge  and  power 
of  conception  and  abstract  thought,  and  a  rather  too 
vivid  imagination.  His  disorder  of  conduct  results 
from  his  exuberance  triumphing  over  his  better  judgment 
and  his  critical  faculties.  The  imbecile's  life  is  due  to 
the  lack  of  these  faculties  and  the  absence  of  those 
powers,  as  well  as  his  feeble  sense  of  morality.  Moreover, 
there  are  no  defects  in  vocabulary  or  articulation  in 
hypomaniacs, 


PART  II 

ATYPICAL    AND    COMBINED 

PSYCHOSES 


CHAPTER  VI 

BORDERLINE  PSYCHOSES 

1.  HYPOMANIA    AND    THE     MANIC-DEPRESSIVE 

DIATHESIS 

A  smalt,  proportion  of  persons  who  pass  muster  among 
their  fellows  as  "highly  strung  or  excitable,"  are  in 
reality  the  subjects  of  chronic  hypomania  or  the  manic- 
depressive  diathesis — a  temperament  rendering  them 
more  liable  to  attacks  of  melancholia  and  mania,  or  mania 
alone,  than  ordinary  persons,  but  shading  off  into  the 
normal.  The  majority  of  them  are  also  prone  to  minor 
attacks  of  depression  (usually  dubbed  "  blues  "  or 
"  liver  "),  which  are  regarded  as  the  counterpart  of  the 
depressed  phase  of  manic-depressive  insanity.  In  well- 
marked  cases  the  constitutional  excitement  results 
in  a  life  of  prodigality,  dissipation,  ill-directed  and  spas- 
modic labour,  without  any  perseverance  or  fixity  of  pur- 
pose. These  persons  are  for  ever  planning,  scheming 
and  expending  vast  quantities  of  energy  along  continually 
changing  channels. 

As  the  result  of  any  particular  stress  or  of  persistent 
opposition,  they  are  very  prone  to  develop  definite 
attacks  of  manic-depressive  insanity.  It  is  not  unlikely 
that  such  attacks,  whatever  their  exciting  cause,  are  the 
result  of  a  process   of  auto-intoxication. 

119 


120    ATYPICAL  AND  COMBINED  PSYCHOSES 

The  general  resemblance  of  their  conduct  to  that  of 
imbeciles  has  been  noticed  under  the  latter  title. 

All  their  symptoms  are  those  of  mania  (or  in  their  less 
frequent  and  conspicuous  depressed  phases,  of  melan- 
cholia) attenuated.  In  the  first  case  for  example — press 
of  occupation,  exuberance,  defective  power  of  sustained 
attention  to  one  topic,  rapid  mental  action,  emotional 
instability,  and  general  alertness,  are  exhibited.  These 
cases  are  to  be  distinguished  from  the  subjects  of  the 
hysterical  temperament,  because  the  latter  are  very  much 
less  likely  to  become  insane  as  the  result  of  some  buffet  of 
fortune. 

Hysterics  are  also  subject  to  periods  of  emotional  and 
intellectual  exaltation,  but  these  are  almost  invariably 
the  result  of  some  external  cause,  however  slight.  They 
are  lifted  up  to  the  skies  by  trifling  pleasurable  incidents 
and  just  as  easily  depressed  by  those  of  opposite  nature. 
The  hypomaniac  in  his  usual  condition  is  not  easily  sub- 
dued by  any  external  agency.  Until  his  depressed  stage 
comes  along,  if  he  be  subject  to  one,  he  is  not  sensitive, 
except  in  his  pride,  nor  self-critical ;  he  has  none  of  the 
personal  misgivings  that  are  the  daily  lot  of  the  hysterical 
person.  After  a  bout  of  exaltation,  in  itself  very  short 
(in  contradistinction  to  hypomaniacs'  prolonged  or 
permanent  states),  the  hysteric  practically  always  suffers 
a  stage  of  this  self-analytical  depression  as  a  reaction. 

The  periods  or  continual  state  of  exaltation  as  well  as 
occasional  periods  of  depression  in  hypomaniacs  are  the 
result  not  of  external  but  internal  causes,  and  arise 
independently  of  circumstances,  although  naturally  they 
may  be  modified  thereby. 

Chronic  hypo-melancholies  present  a  picture  of  atten- 
uated melancholia.  They  seldom  exhibit  any  exalted 
stage  at  all.  Many  of  them  worry  about  their  physical 
health,  which  they  hit  upon  as  an  explanation  of  their 


HYPOMANIA  121 

depression  ;  and  these  cases  are  not  easy  to  distinguish 
from  constitutional  neurasthenia.  The  importance  of  the 
distinction  lies  in  the  fact  that  neurasthenics  under  stress 
of  circumstances  as  a  rule  merely  tend  to  get  an  acute 
exacerbation,  whereas  hypo-melancholies  tend  to  become 
melancholies  ;  a  very  great  practical  difference  involving 
the  question  of  the  relative  liability  to  suicide. 

The  diagnosis  is  mainly  made  from  the  presence  of  the 
physical  symptoms  of  neurasthenia,  and  upon  the  fact 
that  irrepressible  ideas  and  other  psychasthenic  signs  are 
much  more  common  in  the  neurosis.  In  neurasthenia 
there  is  also  more  suggestibility  and  divertibility  in 
mood  than  in  the  other  condition.  Neurasthenics 
moreover  do  not  suffer  from  the  continual  depression 
of  even  mild  melancholies,  nor  from  impediment  of 
will. 

The  points  suggested  above  are  the  result  of  practical 
experience,  but  there  is  some  reason  for  thinking  that  a 
certain  aetiological  relationship  exists  between  the  manic- 
depressive  syndromes  and  neurasthenia,  psychasthenia, 
the  anxiety  neurosis,  and  even  amentia.  This  theory 
is  supported  by  a  certain  family  resemblance  in  symp- 
toms, as  well  as  by  the  view  now  commonly  held  that  they 
are  all  due  in  part  to  some  metabolic  disorder  resulting 
in  auto-intoxication.  Neurasthenics  with  psychasthenic 
symptoms  suffer  from  irrepressible  ideas,  as  well  as  un- 
pleasant somatic  sensations,  indecision,  and  emotional  de- 
pression ;  melancholies,  usually  mild  types,  exhibit  one  or 
more  unpleasant  obsessive  ideas  which  they  cannot  banish, 
painful  somatic  sensations  with  impediment  of  will  and  a 
much  deeper  emotional  depression.  In  neurasthenia  uncon- 
genial occupation  of  the  mind  becomes  a  positive  mental 
pain  ;  in  melancholia  all  mental  action  is  painful.  Melan- 
cholies frequently  manifest  physical  signs  of  neurasthenia, 
especially   in   the   early   stages.     Hysteria   is   probably 


122    ATYPICAL  AND  COMBINED  PSYCHOSES 

closely  related  to  psychasthenia  and  the  anxiety  neurosis 
psychologically  (see  pp.   128  and  135). 

Of  course,  as  noted  above,  there  are  well  marked  clinical 
distinctions  between  neurasthenia  and  melancholia  which 
enable  a  diagnosis  to  be  readily  made  in  the  case  of  ordinary 
severe  melancholia  ;  for  example,  apart  from  the  depth 
and  constancy  of  the  depression,  melancholies'  ideas  are 
frequently  delusionary  (which  is  never  the  case  in  neuras- 
thenia), and  therefore  opposed  in  clinical  character  to 
the  incoercible  ideas  of  neurasthenics.  Nevertheless 
obsessive  ideas  may  develop  through  a  phase  of  doubt 
into  delusionary  convictions,  and  some  cases  of  melan- 
cholia exhibit  all  three  phases.  Self-depreciation  is  not 
nearly  so  common  in  neurasthenia  nor  so  well  marked 
when  present,  as  in  melancholia. 

The  exciting  causes  in  acute  cases  of  neurasthenia  are 
just  as  likely  to  produce  a  picture  of  amentia. 

Occasionally  the  latter  is  the  culminating  condition  in 
severe  cases  of  the  former. 

Exhaustion  symptoms  of  amential  nature  are  commonly 
seen  in  both  mania  and  melancholia  of  acute  type. 

Again,  mild  amential  delusional  cases  in  which  the 
erroneous  ideas  are  rather  felt  as  doubts  bear  no  incon- 
siderable resemblances  to  anomalous  psychasthenic 
patients. 

The  so-called  maniacal  stupor  is  believed  by  some 
alienists  to  be  an  amential  syndrome,  and  not  a  manifest- 
ation of  manic-depressive  insanity  at  all. 

Stoddart  describes  a  condition  "  Anergic  Stupor  "  as  a 
variety  of  intermittent  insanity,  i.  e.,  manic-depressive 
insanity,  distinct  from  melancholic  (circular)  stupor ; 
and  the  symptoms  he  records  are  practically  identical 
with  those  seen  in  what  the  present  writer  has  called 
amentia  attonita.     This  stupor  is  said  to  follow  "  melan- 


ECCENTRICS,   CRANKS,  ETC.  123 

cholic  stupor  or  post-maniacal  stupor  "  as  a  rule,  but 
sometimes  to  occur  primarily. 

Now,  as  noted  above,  this  type  of  case  has  been  rele- 
gated to  the  amentia  group,  but  it  is  probable,  if  it 
develops  imperceptibly  in  sequence  to  melancholic  or 
maniacal  syndromes,  that  it  must  be  a  manic-depressive 
condition  with  exhaustion  symptoms  of  so  severe  a  type 
added,  as  to  render  it  indistinguishable  from  primary 
acute  amentia  attonita. 

The  above  notes  are  merely  suggested  as  indications  of 
some  underlying  related  setiological  factor,  and  cast  no 
doubt  upon  the  clinical  entity  of  the  various  syndromes 
concerned. 

2.  ECCENTRICS,  CRANKS,  MORBIDLY  SUSPICIOUS 
PERSONS,  CHRONIC  PROPAGANDISTS  OF 
IMPRACTICABLE  SCHEMES,  ETC. 

These  persons  are  for  the  most  part  cases  of  paranoia 
without  delusions,  possessors  of  the  anomalous  combina- 
tion of  a  logical  mind,  an  inflexible  will,  a  passionate 
emotional  temperament  abnormally  suppressed,  and 
an  inherent  tendency  to  preconception.  The  features 
of  paranoia  have  already  been  outlined,  but  the  develop- 
ment of  delusions  is  not  necessary  as  an  indication  of 
the  constitution  or  temperament.  It  has  already  been 
suggested  that  the  basis  of  the  temperament  is  due  to 
perversion  or  disorder  of  instinct. 

Examples  are  to  be  found  among  inveterate  recluses 
(the  potential  victims  of  imaginary  persecution),  misers, 
diet  cranks  (such  as  vegetarians),  originators  of  new 
religions,  immoderate  idealists,  militant  suffragette  leaders, 
eternal  litigators,  monomaniacs  (persons  who  subordinate 
the  important  things  of  existence  to  one  fixed  and  imma- 
terial view  of  life,  or  idea). 


124    ATYPICAL  AND  COMBINED  PSYCHOSES 

These  persons,  the  subjects  of  an  intense  egotism,  are 
always  leaders  of  any  paranoiacal  movement  which,  inci- 
dentally, they  pursue  with  indefatigable  determination, 
active  intelligence,  and  in  a  logical  manner  given  the 
truth  of  the  erroneous  preconception  at  its  base.  Even 
when  the  Utopian  condition  for  which  mattoids  (the  so- 
called  altruistic  paranoics)  strive,  is  in  fact  altruistic, 
one  never  finds  them  doing  obscure  spade  work. 

In  short,  mattoids  are  hypocrites  and  self-deceivers, 
boasting  an  altruism  which  is  merely  a  cloak  for  selfish 
love  of  power,  display  or  homage. 

Paranoiacal  propagandists  are  not  to  be  confused  with 
hypomaniacs.  These  latter  never  devote  their  whole 
fives,  indeed,  very  rarely  more  than  a  few  months  on  end, 
to  one  scheme  ;  moreover,  they  exhibit  the  usual  signs  of 
attenuated  mania,  directly  opposed  to  the  inflexibility 
of  the  logical  well  considered  and  dignified  conduct  of  the 
paranoiac. 

Some  eccentrics  and  recluses  are  persons  subject  to 
impulses  of  psychasthenic  nature,  or  arrested  precocious 
dements  with  some  persisting  katatonic  tricks,  which  they 
wish  to  hide,  or  other  more  obvious  lunatics.  But  they 
are  easily  distinguished  from  the  paranoiac.  For  example, 
all  militant  suffragettes  are  not  mattoids  ;  by  far  the 
majority  are  unstable  women  rinding  a  vicarious  outlet  for 
an  emotional  suppression  ;  some  are  high  grade  imbeciles  ; 
not  a  few  hypomaniacs  and  hysterics. 

3.  PSYCHASTHENIA 

Apart  from  depression,  and  ccenesthetic  apprehension, 
and  liability  to  "  mental  "  fatigue,  psychasthenia  is  par 
excellence  the  mental  concomitant  of  neurasthenia. 
The  two  syndromes  however  occur  separately.  It  is  not 
proposed  to  discuss  the  various  clinical  states  of  neurosis 


PSYCHASTHENIA  125 

included  under  the  heading  of  neurasthenia,  they  are 
described  in  textbooks  of  medicine.  When  the  term  is 
used  alone  in  this  book  it  means  neurasthenia  together 
with  anxiety   neurosis. 

As  Tanzi  has  it,  psychasthenia  (which  he  personally 
regards  merely  as  a  manifestation  of  neurasthenia)  is 
the  expression  of  a  diathesis  of  psychical  incoercibility. 
It  includes  three  main  features  any  of  which  may  occur 
alone,  or  more  commonly  perhaps,  one  is  prominent 
and  the  others  rudimentary  ;  but  all  three  may  be  well 
marked  in  one  case. 

(a)  Irrepressible  Ideas. — These  are  ideas  which 
continually  recur  to  the  patient's  mind  at  intervals 
and  quite  irrelevantly  to  his  current  of  thought. 

He  banishes  them  from  consciousness  after  a  struggle, 
but  they  merely  represent  themselves  with  added  per- 
sistence and  accompanied  by  a  more  unpleasant  emotional 
tone  for  further  argument  and  conflict,  until  in  severe 
cases  he  becomes  agitated  and  distressed  almost  beyond 
endurance.  The  irrepressible  ideas  sometimes  take  the 
form  of 

(6)  Obsessions  to  Action. — They  partake  of  the  same 
character  of  incoercibility,  produce  the  same  conflict, 
and  the  same  distress.  They  are  of  two  main  types, 
one  in  which  the  impulse  is  to  some  action  that  the  patient 
regards  as  wicked,  and  hence  which  is  never  (or  only 
under  very  exceptional  circumstances)  yielded  to  ;  and 
the  other  in  which  the  obsession  is  apparently  of  indifferent 
nature  to  which  the  patient  almost  invariably  yields  after 
a  struggle.  If  he  decides  to  hold  out  against  the  obsession 
the  result  is  mental  torment  until  in  the  end  he  capitu- 
lates. 

(c)  Phobias. — These  are  specialized  fears  of  specific 
things,  e.  g.,  the  fear  of  spaces,  open  or  closed  ;  of  microbes, 
responsibility,  blushing,  etc. ;  there  are  about  twenty  of 


126    ATYPICAL  AND  COMBINED  PSYCHOSES 

these  special  phobias,  all  of  which  have  received  euphon- 
ious names. 

The  basis  of  all  the  psychasthenic  symptoms  is  regarded 
as  a  more  or  less  subconscious  constitutional  fearfulness 
(constituting  a  temperament  which  shades  off  into  the 
normal) — a  disturbance  of  the  subconscious  instinctive 
ego  (see  p.  128).  Psychasthenics  are  perfectly  lucid 
and  sane,  and  moreover,  enjoy  a  perfect  autocriticism. 
Some  unfortunate  individuals  are  sufferers  from  this 
unpleasant  syndrome  throughout  their  lives,  others  only 
when  in  ill-health. 

Those  who  yield  to  obsessions  to  action  not  infrequently 
come  under  the  notice  of  the  alienist ;  and  in  the  case  of 
young  people  their  apparently  purposeless  acts  occasionally 
suggest  dementia  prsecox.  With  care  there  is  no  reason 
why  the  two  conditions  should  be  confused  :  even  the 
superficially  similar  conduct  is  essentially  opposed. 
The  psychasthenic  acts  after  a  miserable  struggle  to 
overcome  the  impulse  ;  the  precocious  dement  acts  with 
complete  cynicism.  It  must  not  be  forgotten,  how- 
ever, that  the  latter  type  of  case  not  infrequently  mani- 
fests neurasthenic  and  psychasthenic  symptoms  at  the 
outset. 

The  following  case  is  a  common  example  exhibiting 
several  features  of  interest. 

The  mother  of  a  young  man  of  23  consulted  the  present 
writer  about  her  son,  because  he  was  depressed  and 
moody  and  suffering  from  irrepressible  ideas.  His  con- 
duct was  also  markedly  disordered.  He  was  with  great 
difficulty  persuaded  to  rise  in  the  morning  ;  he  took  a 
couple  of  hours  to  bathe  and  dress,  and  at  his  worst  times 
would  he  in  his  bath  for  some  hours,  and  even  then  only 
get  out  after  his  mother  had  washed  him  !  She  would  call 
him,  and  he  would  agree  to  rise  ;  then,  after  the  lapse  of 
half  an  hour  or  so,  he  would  be  found  still  in  bed ;  then  f ol- 


PSYCHASTHENIA  127 

lowed  another  promise  to  get  up  which  would  not  be  kept, 
until  she  remained  with  him  and  insisted  upon  his  rising 
in  her  presence.  The  same  performance  occurred  in  his 
bath,  culminating  at  times  in  the  fashion  recorded  above. 

On  seeing  the  son,  one  noted  that  his  health  appeared 
good  ;  he  manifested  no  signs  of  neurasthenia  ;  and  his 
manner  was  quite  normal. 

A  devout  worshipper  at  the  shrine  of  psycho-analysis 
would  doubtless  have  proceeded  at  once  to  psycho- 
analyze, and  after  much  soul-searching  and  reducing 
the  patient  to  a  state  of  nervous  exhaustion,  would  have 
succeeded  in  unearthing  some  suppressed  sexual  conflict 
which  lay  almost  on  the  surface  of  the  soil,  to  be  obtained 
for  the  asking. 

The  boy  was  quite  frank,  and  a  few  moments  of  sym- 
pathetic conversation  rendered  the  case  quite  clear. 
His  irrepressible  ideas  did  happen  to  be  of  sexual  nature  ; 
he  had  practised  masturbation  and  felt  very  guilty 
therefrom.  His  conduct  was  the  combined  result  of  a 
subconscious  sense  of  uncleanness  and  his  struggles  with 
his  irrepressible  ideas,  which  he  had  to  banish  repeatedly 
before  and  during  the  process  of  dressing,  etc. 

His  mother  was  a  neurotic  widow  ;  his  father  a  drunk- 
ard ;  he  himself  a  spoilt,  carefully  protected  and  mother- 
mollicoddled  boy.  He  knew  nothing  of  life,  except  art ; 
had  no  fixed  occupation,  and  had  never  associated  with 
other  boys,  although  he  had  never  been  particularly 
delicate  or  subject  to  nervous  affections.  (In  point  of 
fact,  he  looked  the  picture  of  health,  stout  and  rosy). 

Common-sense  conversation  and  advice  effected  con- 
siderable improvement,  but  both  mother  and  son  declined 
to  adopt  the  alterations  in  the  mode  of  the  patient's 
life  that  were  suggested,  and  so  after  a  few  weeks  the 
case  was  lost  sight  of  for  some  months.  When  seen  again 
there   were  no  complaints  of   his  conduct  nor  did  he 


128    ATYPICAL  AND  COMBINED  PSYCHOSES 

confess  to  any  further  attacks  of  irrepressible  ideas  or 
impulses. 

The  following  theories  concerning  the  neuroses  are 
favoured  by  the  present  writer  : — 

The  ordinary  environmental  conditions  of  life  tend 
in  certain  individuals  to  produce  undue  reactions  to  fear. 
Expressions  of  this  fear  (involving  the  conscious  admis- 
sion of  the  conflict  between  environment  and  instinct), 
in  such  persons  are  suppressed  into  the  subconscious,  but 
when  the  suppression  fails,  perhaps  as  the  result  of  worry 
or  ill-health,  and  the  failure  is  partial,  the  emotional  tone 
of  fear  returns  to  consciousness  disguised  as  an  irrepres- 
sible idea,  phobia,  or  obsession  to  action.  Thus  is  psy- 
chasthenia  produced.  The  constitutional  fearfulness  is 
the  psychasthenic  temperament,  constituting  a  liability  to 
such  symptoms,  but  shading  off  into  the  normal.  Complete 
failure  of  suppression  and  disguise,  from  worry,  illness,  etc., 
etc.,  resulting  in  conscious  conflict,  produces  in  such  per- 
sons the  anxiety  neurosis  (agitated  neurasthenia).  Auto- 
intoxication is  associated  with  the  anxiety  neurosis  (as 
well  as  with  asthenic  neurasthenia),  and  if  very  severe, 
may  result  in  amentia.  Persons  without  obviously  psy- 
chasthenic temperaments  may,  of  course,  suffer  from  the 
anxiety  neurosis  and  amentia,  but  the  exciting  con- 
ditions must  be  more  severe  in  such  cases.  Pure  asthenic 
neurasthenia  is  not  associated  with  the  psychasthenic 
temperament,  but  is  due  to  an  overdraft  on  the  indivi- 
dual's capital  of  nervous  energy.  Constitutional  types 
simply  indicate  that  ordinary  life  constitutes  this  over- 
draft in  their  case. 


4.  "MASKED"  EPILEPSY  AND  AUTOMATISM 

The  episodic  attacks,  permanent  psychopathic  states, 
and  temperament  of  epileptics  have  already  been  noticed, 


"MASKED"   EPILEPSY   AND   AUTOMATISM     129 

These  were  considered  when  associated  with  fits.  Some 
persons  however  are  met  with  who  do  not  appear  to  suffer 
from  fits  (major  or  minor),  or  obvious  psychoses,  nor 
betray  any  signs  of  mental  enfeeblement ;  but  manifest 
certain  slight  anomalies  of  temperament  and  mental  life 
which  are  usually  attributed  to  larval  epilepsy. 

The  most  common  of  these  manifestations  is  depression 
of  spirits,  periodical  and  causeless  so  far  as  external 
circumstances  are  concerned.  Regularly  once  in  every 
few  weeks  a  feeling  of  gloom  overtakes  these  patients  ; 
life  seems  dark  and  difficult  and  they  become  miserable 
and  irritable,  or  bitter.  They  shun  their  acquaintances, 
to  whom  they  are  rude  or  churlish.  Intimate  knowledge 
of  these  persons  sometimes  enables  one  to  demonstrate 
occasional  nocturnal  enuresis  or  tongue-biting,  momentary 
attacks  of  giddiness  or  confusion,  and  always  some  indica- 
tions of  the  epileptic  temperament.  They  are  sensitive, 
conscientious,  painstaking,  and  of  a  serious  turn  of  mind  ; 
but  if  offended,  they  are  vindictive  and  manifest  the 
obvious  "  wound-up  "  temper  ;  they  brood  over  imagin- 
ary "  slights,"  and,  more  especially  at  the  depressed 
period,  are  apt  to  imagine  that  they  are  insulted,  and 
generally  to  misconstrue  their  friends'  manners  and 
remarks.  Violent  outbursts  of  rage  without  much 
provocation  are  common. 

But  these  characteristics  represent  the  full  extent  of 
their  permanent  psychopathic  abnormality ;  actual 
and  repeated  fits  appear  to  be  essential  in  the  production 
of  any  degree  of  intellectual  enfeeblement. 

The  periodical  attacks  of  depression  culminate  in  some 
persons  in  an  alcoholic  debauch  (an  act  entirely  contrary 
to  their  usual  tendencies),  followed  in  a  few  cases  by  an 
attack  of  confusion  or  some  other  state  of  excitement. 
These  are  the  so-called  dipsomaniacs. 

The  periods  of  gloom  are  equivalents,  and  are  therefore 

e.m.d.  9 


130    ATYPICAL  AND   COMBINED  PSYCHOSES 

frequent,  causeless,  short  in  duration  (a  few  days),  similar 
and  periodical.  These  features  distinguish  them  from 
other  forms  of  depression.  The  temperament  is  regarded 
as  a  special  variety  of  inherent  instability,  the  possessor 
of  which  is  particularly  prone  to  develop  epileptic 
episodes  and  fits.  In  not  a  few  of  the  cases  of  this  type, 
a  history  of  fits,  night-terrors,  somnambulism,  etc.,  in 
childhood,  is  forthcoming. 

The  importance  of  recognizing  masked  epilepsy  lies  in 
the  fact  that  its  subjects  may  at  any  time  under  stress  of 
circumstances  develop  definite  epileptic  syndromes  or 
fits. 

Automatism  (roughly  to  be  described  as  apparently 
conscious  action  committed  in  a  semi-conscious  dream- 
like condition  and  subsequently  forgotten)  occurring  in 
sane  people,  apart  from  hypnotism,  is  in  the  writer's 
opinion  an  expression  of  epilepsy  or  hysteria.  Some 
patients  while  in  this  state  appear  to  behave,  to 
casual  observers,  as  if  nothing  was  amiss,  showing  that 
consciousness  is  not  so  much  clouded  as  dissociated  from 
that  characterizing  the  ordinary  life  of  the  patient.  In 
these  types  the  sense  of  personal  identity  is  not  lost ; 
the  intellectual  life  is  merely  cut  up  into  separate  periods, 
the  normal  and  the  automatic,  mutually  forgotten  in  the 
other,  and  not  infrequently  remembered  in  the  same  ; 
that  is  to  say,  similar  representations  may  occur  in  each 
successive  attack  of  automatism  accompanied  by  recol- 
lection of  the  events  of  previous  attacks  which  in  the 
normal  periods  are  completely  irrecoverable  ;  also  much 
more  rarely,  temporary  retrograde  amnesia  extending 
over  previous  normal  periods  (as  well  as  automatic)  may 
be  present  after  an  attack. 

A  soldier  was  admitted  to  my  wards  in  a  state  of  com- 
plete disorientation.  He  thought  he  had  just  come 
down  the  fine  to  Fricourt  and  that  the  hospital  was  a 


"MASKED"   EPILEPSY   AND   AUTOMATISM    131 

rest  camp  at  that  place.  He  was  completely  accessible, 
talked  logically,  and  it  was  impossible  to  convince  him 
by  argument  that  his  ideas  were  erroneous.  He  said 
however  that  he  had  dreamt  that  he  had  been  invalided 
home.  When  taken  outside  the  hospital  and  shown  the 
sea,  landscape,  and  passers-by,  he  "  woke  up  "  gradually, 
and  immediately  complained  of  pain  in  his  head  and 
became  rather  agitated  and  emotional.  (See  hysteria, 
p.  146,  for  psychology  of  cases  of  this  sort.) 

The  automatism  in  these  cases  may  persist  for  some 
weeks,  and  is  to  be  regarded  as  hysterical.  Other  much 
more  common  varieties  of  automatism  are  shorter  and 
obviously  insane,  e.g.,  when  blind,  purposeless  or  criminal 
acts  are  committed.  These  for  the  most  part  occur  in 
known  epileptics  or  masked  cases  under  the  influence  of 
alcohol. 

One  of  the  best  marked  attacks  of  automatism  that  the 
present  writer  has  encountered  was  in  a  soldier  of  twenty- 
one  years  of  age  who  was  recently  admitted  to  the  observa- 
tion wards  of  a  military  hospital. 

On  admission  he  was  stuporose  and  mute  ;  he  obeyed 
simple  commands,  but  appeared  completely  disorientated 
and  vacant.  Yet  there  was  no  individual  imperception, 
nor  active  disorder  of  conduct.  Physically,  there  was 
nothing  worthy  of  note,  but  dilated  pupils  and  an  old 
bullet  wound  in  his  chest. 

The  following  day  he  was  completely  collected  and 
reasoned  logically  ;  by  inquiry  he  had  discovered  his 
whereabouts,  and  in  all  save  one  particular  was  mentally 
normal,  viz.  he  exhibited  complete  amnesia  extending 
backwards  for  about  three  years  from  that  day.  For 
example,  he  found  in  his  pocket  a  photograph  of  a  woman 
and  a  baby.  He  showed  this  to  me  with  the  remark 
that  the  woman  was  the  girl  he  was  "  keeping  company 
with,"   but  whose  baby  it  was  he  had  no  idea.     He 


132    ATYPICAL  AND  COMBINED  PSYCHOSES 

thought  that  the  present  year  was  1912,  and  that  he  was 
in  the  Grenadier  Guards,  as  in  fact  he  had  then  been. 
He  only  discovered  the  loss  of  these  three  years  from 
conversation  with  the  other  patients,  from  whom  he  also 
obtained  the  news  that  a  war  was  in  progress  !  On  the 
next  day  he  received  a  letter  from  the  "  girl  he  was  keeping 
company  with."  She  had  been  his  wife  for  over  two 
years,  and  the  child  in  the  photograph  was  his  own. 

During  the  succeeding  week  his  memory  gradually 
returned,  much  to  his  own  satisfaction,  until  eventually 
he  remembered  everything,  except  some  half-dozen 
short  periods  in  his  life,  periods  ranging  from  a  few 
hours  to  some  days,  of  which  he  was  cognisant  only  from 
the  accounts  of  his  friends.  These  mnemonic  scotomata 
proved  upon  inquiry  to  have  been  attacks  of  automatism. 
During  each  attack  he  had  attempted  suicide,  twice  by 
drowning,  once  by  throwing  himself  on  to  a  railway- 
line,  once  by  shooting  himself  with  his  rifle  (the  result 
of  which  was  the  scar  mentioned)  and  in  other  ways. 
On  one  or  two  occasions  he  had  come  to  himself  at  the 
near  approach  of  death. 

These  facts  were  verified  by  external  evidence.  In 
childhood  this  man  had  suffered  from  fits  ;  evidence  of 
only  one  in  a  later  life  was  obtainable — at  the  age  of  19. 

5.   THYROID    PSYCHOSES    AND    THEIR 
RELATIONSHIPS 

The  physical  symptoms  of  myxcedema  are  well  known. 
The  chief  mental  features  are  general  retardation  of 
mentation,  lethargy,  and  impairment  of  attention  resulting 
in  amnesia  for  recent  events. 

Cretins  show  varying  degrees  of  intellectual  defect 
analogous  to  cerebropathic  idiots,  as  well  as  characteristic 
physical  signs. 


THYROID  PSYCHOSES  133 

Exophthalmic  goitre  is  richer  in  mental  pictures. 
The  subjects  of  Grave's  disease  may  be  said  to  enjoy  a 
special  temperament  (or  is  it  that  persons  of  such  type 
develop  Grave's  disease  ?).  They  are  irritable,  easily 
angered,  egotistical,  wilful  and  domineering — in  their 
more  comfortable  periods — and  subject  to  attacks  of 
apprehension  associated  with  the  crises  of  their  disease. 

In  worse  cases  this  state  of  fear  persists  more  or  less 
permanently  in  a  less  marked  form,  and  occasionally 
phobias  similar  to  those  of  psychasthenia  are  present. 

Grave's  disease  frequently  follows  psychical  traumatism, 
either  acute,  such  as  fright  and  sudden  bad  news,  or 
subacute,  such  as  prolonged  stress  or  worry. 

It  is  important  to  bear  in  mind  in  this  connexion  that 
neurasthenia  (anxiety  type)  or  amentia  following  these 
causes  may  leave  a  condition  of  exophthalmic  goitre  in  its 
wake.  On  the  other  hand,  early  stages  of  Grave's 
disease  often  present  symptoms  indistinguishable  from 
such  neurasthenia,  and  severe  cases  of  the  latter  are 
sometimes  subject  to  transitory  attacks  of  tachycardia 
and  exophthalmos.  This  is  often  seen  in  shell  shock 
anxiety  neuroses. 

In  fact  the  relationship  of  anxiety  neurasthenia  to 
Grave's  disease  is  perhaps  much  closer  than  is  usually 
recognized.  This  relationship  is  seen  in  the  similarity 
of  exciting  cause  ;  in  the  similarity  of  symptoms,  physical 
and  psychical,  and  in  the  co-existence  and  mingling  of 
signs  of  the  two  conditions  in  single  cases. 

Acute  agitated  neurasthenics  present  a  picture  of  fear, 
both  in  physical  signs  and  mental  symptoms  ;  the  sub- 
jects of  Grave's  disease  exhibit  practically  identical  fea- 
tures, with  exophthalmos  and  thyroid  enlargement  added. 
Elevation  of  the  upper  eyelid  (a  physical  sign  of  fear)  is 
almost  the  rule  in  acute  anxiety  neurasthenia. 

It  is  at  least  a  feasible  hypothesis  that  the  two  affections 


134    ATYPICAL  AND  COMBINED  PSYCHOSES 

are  due  in  part  to  similar  auto-intoxication,  resulting 
from  a  related  disturbance  of  the  sympathetic  system  or 
the  ductless  glands — not  improbably  both,  as  they  are 
known  to  be  closely  connected. 

Persons  with  exophthalmic  goitre  would  appear  to  be 
especially  liable  to  attacks  of  apprehensive  excitement, 
mania,  and  amentia  agitata.  Transitory  attacks  of 
exophthalmos  with  goitre  have  been  described  in  cases  of 
dementia  prascox,  and  undoubtedly  do  occur  fairly 
commonly. 

Such  attacks,  however,  are  also  known  to  occur  fre- 
quently in  sane  young  people,  and  there  is  as  yet  not 
sufficient  evidence  to  warrant  an  assumption  of  any 
connexion  between  the  psychosis  and  Grave's  disease. 

Nevertheless  the  close  connexion  between  the  sexual 
glands  and  the  thyroid  and  other  internal  secretory 
glands  is  well  recognized  ;  and  when  one  reflects  that  some 
disturbance  of  sexual  metabolism  is  regarded  as  an  setio- 
logical  factor  in  the  production  of  dementia  prsecox, 
occasional  thyroid  disturbance  is  not  surprising. 

The  following  case  is  not  without  interest  in  connexion 
with  the  association  of  symptoms  of  Grave's  disease 
with  other  syndromes  : 

A  girl  of  30 — always  highly  strung,  clever,  artistic, 
ambitious,  good-hearted  but  egotistical — developed  ae 
the  result  of  a  severe  psychical  shock  an  acute  neuras- 
thenic condition.  While  she  was  under  treatment  for 
this  an  attack  of  amential  confusion  supervened,  during 
which  she  was  involved  in  a  severe  accident.  No  bones 
were  broken,  and  after  some  weeks  of  hospital  she  was 
sent  home,  still  exceedingly  weak,  depressed  and  neur- 
asthenic. At  this  time  there  was  present  tachycardia 
and  some  degree  of  exophthalmos.  After  some  weeks 
these  symptoms  gradually  passed  off  and  there  was  marked 
general   improvement.     Then    followed    an   indiscretion 


HYSTERIA  135 

(over-exertion)  accompanied  by  another  minor  psychical 
shock,  with  the  immediate  result  that  the  exophthalmos 
and  tachycardia  returned.  The  day  following  she  was 
very  depressed  and  lachrymose,  and  another  confusional 
attack  supervened.  The  latter  passed  off  in  a  few  days 
and  she  gradually  began  to  regain  her  strength,  the 
exophthalmos  and  tachycardia  disappearing  'pari  passu 
with  the  neurasthenia. 

After  passing  through  a  phase  of  hopelessness  concerning 
her  eventful  recovery  (urgently  combated  by  suggestion — 
not  hypnotic)  she  gradually  grew  fat  and  made  an  almost 
complete  recovery,  after  about  ten  months  from  the 
original  onset.  Some  months  later  while  still  physically 
well  she  developed  an  attack  of  hysterical  excitement. 
No  physical  signs  of  any  sort  were  present.  She  began 
to  manifest  delusions  of  sexual  import.  Subsequently 
she  was  lost  sight  of. 

6.  HYSTERIA 

Hysteria  is  a  disorder  of  the  subconscious  personality, 
by  which  is  meant  that  complex  of  affective  tones, 
instincts,  tendencies,  mnemonic  symbols  of  ideas,  kinEes- 
thetic  images,  preconceptions,  psycho-organic  connexions 
— which  is  so  difficult  to  define  and  delimit,  but  well 
recognized  to  exist  and  to  play  an  important  part  in 
the  constitution  of  the  ego  and  the  conduct  of  the 
individual. 

According  to  the  view  advocated  here  the  basis  of 
the  disorder  is  a  hyper-excitability  of  the  subconscious 
instinctive  ego.  Two  manifestations  of  hysteria  may  be 
recognized  clinically  ;  the  hysterical  temperament,  and 
the  episodic  attacks.  Both  are  too  well  known  to  call  for 
description. 

The  temperament,  like  all  other  "abnormal"  tempera- 


136    ATYPICAL  AND  COMBINED  PSYCHOSES 

ments,  varies  in  intensity  in  different  persons,  and  shades 
off  by  imperceptible  gradations  into  the  normal.  It  is 
regarded  as  due  to  a  chronic  hyperexcitability  of  the 
subconscious  instinctive  self,  often  directly  inherent, 
indicating  an  excessive  liability  to  hysterical  episodes. 
This  liability  being  a  question  of  degree  as  compared 
with  apparently  normal  persons,  it  is  likely  that  the  latter 
may  be  capable  of  developing  it  temporarily  or  per- 
manently as  the  result  of  external  stimuli.  It  is  found 
that  causes  of  emotional  upheaval  in  persons  previously 
manifesting  no  hysterical  temperament  can  result  in 
hysterical  episodes  ;  such  episodes  are,  however,  natur- 
ally more  easily  produced  in  obviously  hysterical  people. 
The  mechanism  at  work  in  the  production  of  hysterical 
somatic  episodes  (e.g.,  ansesthesia,  paralysis,  etc.)  accord- 
ing to  the  theory  enunciated  above — the  over  excitability 
of  the  instinctive  subconscious  in  hysteria — is  as  follows  : 


A.LOWER    SENSORf  MOTOR.  AREAS    8.  VASO-MOTOR  AND  SYMPATHETIC  SYSTEMS 

C.  SUBCONSCIOUS    EGO,    INCLUDING   C1..  MNEMONIC    SYMBOLS   ETC.  C" INSTINCTS  ETC. 

D.  CENSURE      E.  CONSCIOUSNESS,    JUDGMENT.    WILL,  HIGHER    CONTROL-      " 

'•A  sensory  stimulus  (a)  with  its  kinetic  tendency  is  received  by  the 
sensori-motor  areas  (A),  from  which  it  travels  as  a  jDotential  sensation 

Only  powerful  stimuli  are  germane  to  this  subject.  The 
diagram  is  of  course  only  a  simple  psychological  picture  of  a 
complicated  process.  Such  questions  as  to  whether  sensation, 
perception,  etc.,  occur  in  consciousness  before  interaction  of  the 
results  of  the  stimulus  with  the  instincts  and  vaso-motor  systems, 
etc.,  are  immaterial  to  the  thesis  of  this  section. 


HYSTERIA  137 

(6)  with  a  kinetic  tendency  to  (B)  the  vaso-motor  and  sympathetic 
systems,  where  organic  reactions  occur  and  add  to  it  a  potential  affective 
tone  (c).  By  means  of  psycho-organic  connexions  the  subconscious 
ego  is  reached,  and  here  (C)  interactions  occur  between  the  potential 
affective  tone  with  its  kinetic  tendency  on  the  one  hand,  and  the  in- 
stincts on  the  other  ;  and  by  association  subconscious  Symbols  of  ideas, 
associated  experiences,  and  their  affective  tones,  are  aroused.  Instincts 
consist  of  inherent  kinetic  tendencies  with  affective  tones,  and  if  the 
potential  affective  tone  of  the  stimulus  is  out  of  harmony  with  the 
instincts,  the  resultant  of  the  interaction  is  a  potential  unpleasant 
affective  tone  (d)  and  an  instinctive  tendency  to  action  (e)  accompany- 
ing the  potential  sensation  (b)  and  the  aroused  associated  mnemonic 
symbols  (/)  to  consciousness  (E). 

If  consciousness  as  the  result  of  a  stimulus  experiences 
an  unpleasant  affective  tone,  it  will  also  experience  a 
tendency  to  action  in  relation  thereto.  At  the  same 
time  sensation,  perception,  cognition,  etc.,  take  place. 

Now  three  courses  are  open  to  the  conscious  higher 
control.  One  is  to  act  in  accordance  with  the  instinctive 
tendency  to  action,  thus  dissipating  the  unpleasant 
affective  tone.  Such  is  instinctive  action.  The  second 
is  to  admit  the  unpleasant  tone  and  the  natural  tendency 
to  action.  To  decide  if  such  action  conflicts  with  the 
higher  judgment,  principles  or  environment,  and  if  so, 
to  recognize  the  antagonism,  and  act  in  opposition  to 
the  tendency,  tolerating  the  unpleasant  tone  until  such 
time  as  it  can  be  sublimated  in  action  that  does  not 
conflict  with  the  higher  judgment,  etc.  The  third  is  to 
suppress  the  whole  resultant  of  the  original  stimulus 
(the  complex)  into  the  subconscious.  This  last  method 
again  would  be  employed  as  an  alternative  to  instinctive 
action  where  the  latter  conflicted  with  the  higher  person- 
ality or  environment.  The  normal  healthy  procedure 
where  such  was  the  case  would  be  the  second  method, 
but  certain  individuals,  notably  persons  of  hysterical 
temperament,  almost  invariably  suppress  at  once  the 
unpleasant  complex.  Hysterical  people  do  so  because 
they  are  intolerant  of  unpleasant  affective  tones,  owing 


138    ATYPICAL  AND  COMBINED  PSYCHOSES 

to  their  emotional  exaltation ;  such  tones  would  tend 
to  overflow  as  inimical  emotions.  The  more  severe 
the  emotional  tone,  therefore,  the  greater  the  tendency 
to  suppress  it  if  instinctive  dissipation  is  forbidden. 

The  next  step  in  the  mechanism  then  is  the  suppression 
into  the  subconscious  of  the  complex.  This  suppression 
is  originally  conscious,  but  becomes  subconscious  when  it 
is  accomplished,  though  still  liable  to  become  conscious  at 
times.  Eventually  in  many  cases  the  original  conscious 
suppression  is  forgotten  and  the  inhibition  remains 
completely  upon  the  subconscious  plane  until  it  is 
strongly  antagonized  or  broken  through  by  further 
stimuli. 

The  psychological  agent  of  this  suppression  once 
achieved  is  called  the  censure.  It  is  not  unlikely  that 
the  censure  is  always  subconsciously  at  work  in  maintain- 
ing a  partial  inhibition  of  the  reactions  of  afferent  stimuli 
to  consciousness,  just  as  in  the  neurological  sphere  the 
upper  motor  segment  exercises  an  inhibitive  action  upon 
the  lower. 

It  should  be  made  clear  that  the  censure  is  a 
normal,  not  an  hysterical,  mechanism  ;  also  that  sup- 
pression is  not  necessarily  an  hysterical  act.  But 
the  suppression  being  accomplished  and  maintained, 
the  mechanisms  of  hysteria  come  into  play  ;  the  over 
excitable  subconscious  instinctive  quota  is  further 
excited  and  stimulated  by  the  suppression.  The  instinct 
already  and  always  hyperexcited,  thus  thwarted  of 
expression  in  action,  is  reinforced  by  the  kinetic  tendency 
of  the  complex  and  tends  to  overflow  violently  into  con- 
sciousness once  more.  In  response  the  censure  acts 
strongly,  and  (as  is  often  the  case  in  physiology)  undue 
stimulus  results  in  overaction  ;  not  only  is  the  complex 
prevented  from  reaching  consciousness,  but  other  afferent 
stimuli  as  well. 


HYSTERIA  139 

If  this  overaction  on  the  part  of  the  censure  be  very- 
pronounced,  inhibition  of  the  results  of  stimuli  in  their 
passage  to  consciousness  from  many  areas  of  sensation 
occurs,  and  the  hysterical  states  of  dissociation  of  con- 
sciousness (somnambulism,  automatism,  stupor)  super- 
vene. Less  wide  overaction  of  the  censure  results  in 
cutting  off  from  consciousness  of  kinesthetic  images 
through  the  inhibition  of  muscular  and  other  afferent 
necessary  stimuli,  and  hence  in  paralyses.  Similar  inhibi- 
tion of  sensory  peripheral  stimuli  produces  anaesthesias 
(vide  h.  j.  k,  afferent  stimuli  from  part  involved  by 
somatic  episode).  The  close  association  of  the  sym- 
pathetic and  vaso- motor  systems  with  affective  tones 
and  emotions  is  well  known.  It  is  not  surprising  therefore 
to  find  that  the  powerful  instinctive  affective  tone  of 
the  suppressed  complex  in  hysteria  often  disturbs  those 
systems.  Since  instincts  possess  an  affective  tone,  and 
all  affective  tones  are  dependent  upon  vaso-motor  and 
sympathetic  reactions,  it  will  be  obvious  that  hyper- 
excitability  of  the  instincts  must  necessarily  involve 
hyperexcitability  of  those  systems.  This  being  the  case 
it  is  possible  that  vaso-motor  somatic  episodes  are  pro- 
duced as  follows  : —  The  unpleasant  affective  tone  result- 
ing from  the  original  stimulus,  prior  to  suppression,  is 
in  part  due  to  the  contractive  power  upon  the  peripheral 
vessels  of  the  vaso-motor  centre.  (It  has  been  shown 
that  such  contraction  occurs  in  unpleasant  affective 
states.)  The  centre  tends  to  gradually  relax  this  undue 
contraction  either  with  the  removal  of  the  stimulus  and 
hence  the  affective  tone  or  with  the  dissipation  of  the 
latter  by  instinctive  action.  In  any  case  the  relaxation 
would  be  gradual.  When  suppression  occurs,  however, 
the  centre  is  suddenly  called  upon  to  relax  without  either 
of  the  normal  stimuli  to  relaxation.  Being  already 
overexcitable  it  relaxes  its  tension  irregularly  and  perhaps 


140    ATYPICAL  AND  COMBINED  PSYCHOSES 

excessively  as  concerns  certain  areas,  and  oedemas  or 
haemorrhages  result. 

Whether  such  an  hypothesis  of  the  actual  patho- 
genesis of  such  vascular  episodes  is  regarded  as  reasonable 
or  not,  the  close  connexion  between  hyperexcitability 
of  the  subconscious  instinctive  ego  and  a  hyperexcitability 
of  the  vaso-motor  and  sympathetic  systems  will  be 
apparent. 

The  actual  site  of  hysterical  somatic  episodes  is  pro- 
bably determined  by  the  associations  aroused  amongst 
the  subconscious  mnemonic  symbols  by  the  stimulus, 
often  images  of  previous  slight  injuries  to  the  part  in- 
volved in  the  episode,  or  as  the  result  of  disturbance  of 
the  ccenesthesis  arising  from  abnormal  stimuli  from  the 
part. 

The  episodes  serve  in  some  degree  to  satisfy  the  instinct 
which  is  thwarted  by  the  suppression.  In  some  cases 
the  instinct  involved  is  easily  apparent,  e.g.,  when  a 
soldier  on  active  service  develops  a  paralysis.  The 
presence  of  epigastric  anaesthesia  is  probably  explained 
by  the  fact  that  fear  complexes  are  associated  with  un- 
pleasant epigastric  sensations.  Pressure  over  the  epigas- 
trium in  these  cases  may  bring  about  fits  or  emotional 
crises.  Cases  in  which  ovarian  pressure  causes  these 
storms  are  probably  of  sexual  origin. 

Failure  of  suppression  is  due  to  stimuli  causing  sub- 
conscious association  with  the  suppressed  complex, 
and  as  a  result  of  this  association  a  summation  of  stimuli 
occurs  ;  the  kinetic  tendency  of  the  stimuli  is  added  to 
that  of  the  suppressed  complex,  the  censure  is  broken 
through,  and  the  complex  thus  reinforced  reaches  con- 
sciousness once  more  with  added  tendency  to  instinctive 
action  and  a  more  intense  affective  tone.  Emotions, 
crises  or  fits  may  then  result — and  incidentally,  the  tem- 
porary or  permanent  cure  of  the  somatic  episode,  accord- 


HYSTERIA  141 

ing  to  the  fashion  in  which  the  higher  control  treats  the 
revived  complex.  The  breaking  down  of  the  inhibition 
of  the  censure  by  summation  of  stimuli  is  the  basis  of 
methods  directed  towards  the  cure  of  somatic  episodes. 
Hypnotism,  partial  anaesthesia  with  suggestion,  and 
psycho-analysis  are  simply  methods  of  applying  the 
stimulus  to  the  subconscious.  The  stronger  the 
stimulus  the  more  likely  is  it  to  be  effective,  and 
the  strength  of  a  stimulus  being  dependent  upon 
its  potential  affective  tone,  it  follows  that  one  pro- 
ductive of  emotion  is  most  efficacious.  Dreams  by 
association  and  from  their  affective  tones,  occasionally 
cure  hysterical  episodes.  Dreams  are  in  fact  more  or  less 
disguised  fulfilments  of  thwarted  instincts  ;  the  affective 
tone  and  tendency  to  action  of  the  suppressed  complex 
are  more  or  less  satisfied,  and  therefore  the  episode  dis- 
appears. The  only  difference  between  cure  by  dream  and 
cure  by  psycho-therapeusis  is  that  in  the  former  case  the 
summating  stimulus  is  immediately  of  internal  origin. 

One  would  expect  that  association  should  occur  most 
readily  between  the  suppressed  complex  and  the  resultants 
of  the  curative  stimulus  when  the  latter  affected  the 
instinct  involved  in  the  suppression.  This  is  in  fact 
found  to  be  the  case.  Stimuli  productive  of  fear  cure 
episodes  due  to  suppression  of  self-preservation  com- 
plexes ;  those  causing  shame,  etc.,  episodes  of  sexual 
origin.  Very  severe  stimuli  however  may  cure  episodes 
by  overflow  association  whatever  the  instinct  affected 
by  the  suppression. 

Hypnotic  suggestion  produces  an  artificial  dream  in 
which  the  stimuli  that  summate  are  supplied  by  the 
physician.  The  suggestible  part  of  the  ego  is  the  sub- 
conscious ;  an  overexcitability  of  this  (according  to  our 
theory)  therefore  explains  the  remarkable  suggestibility 
of   hysterics.     Persons    undergoing    psycho-analysis    are 


142    ATYPICAL  AND  COMBINED  PSYCHOSES 

partially  hypnotized  by  the  process  ;  the  physician  sup- 
plies stimuli  tending  to  produce  an  affective  state  asso- 
ciated with  the  suppressed  complex  which  is  thereby 
reinforced  and  breaks  the  censure. 

Hysterical  somatic  episodes  due  to  isolated  and  not  con- 
tinuous stimuli  tend  to  spontaneous  cure  in  course  of  time, 
just  as  a  normal  man  is  able  to  contemplate  after  the  lapse 
of  time,  without  unpleasant  affective  tone,  the  memory 
of  past  unhappy  incidents.  So  in  hysteria  the  mnemonic 
images  of  the  suppressed  complex  are  able  to  become 
memories  because  the  affective  tone  has  faded  away  ; 
the  censure  letting  them  through  to  consciousness,  the 
episode  disappears.  The  mechanism  of  sex  hysterical 
episodes  differs  only  from  that  of  fear  episodes  in  that 
the  stimuli  producing  them  arise  more  or  less  solely  from 
within  (i.  e.,  from  the  sexual  organs),  and  are  more  or 
less  continual.  Some  persons  of  great  hyperexcitability 
of  this  instinct  develop  episodes  without  any  special 
external  experience  necessitating  suppression  ;  the  sexual 
complexes  are  suppressed  without  such.  The  reason 
for  this  suppression  is  to  be  looked  for  in  early  training. 
Stimuli,  whether  external  or  internal,  tending  to  reinforce 
the  sexual  instinct  would  first  reach  consciousness  with 
a  pleasant  affective  tone,  therefore  even  persons  of  hys- 
terical temperament  would  feel  no  impulse  to  suppress. 
The  complex  even  if  environment  forbade  immediate 
satisfaction  of  the  instinctive  tendency,  would  remain 
conscious,  because  it  was  pleasant,  until  it  could  be 
sublimated  or  satisfied.  Early  training  however  in 
these  matters  is  almost  invariably  directed  towards  the 
suppression  of  the  sexual  instinct,  not  its  consideration 
and  sublimation.  That  is  to  say  young  people  are  taught 
to  suppress  the  instinctive  complexes.  Their  subsequent 
reappearance  in  gradually  increasing  insistence  therefore 
is  really  a  failure  of  suppression,  a  breakage  of  the  censure, 


HYSTERIA  143 

and  is  in  consequence  accompanied  by  an  unpleasant 
tone.  The  hysteric  therefore  suppresses  the  whole 
complex  again,  and  if  his  excitability  is  sufficiently 
pronounced  episodes  occur  in  the  ordinary  way.  Persons 
of  less  marked  hysterical  temperament  may  need 
powerful  external  stimuli,  such  as  disappointment  in  love, 
to  bring  about  episodes.  Hysterical  episodes  due  to 
sexual  suppression  without  any  particular  external 
stimulus,  tend  only  to  disappear,  spontaneously,  with  the 
decay  of  the  instinct. 

Two  factors  then,  to  sum  up,  are  necessary  for  the 
development  of  hysterical  somatic  episodes,  suppression 
of  complexes  and  a  hyperexcitability  of  the  subconscious 
instinctive  ego.  It  will  be  seen  moreover  that  the  two 
factors  are  interdependent.  The  emotionalism  resulting 
from  the  hyperexcitability  involving  the  vaso-motor 
and  sympathetic  systems,  renders  unpleasant  affective 
states  intolerable,  hence  they  are  suppressed  at  once. 
The  suppression  again  increases  the  excitability,  and  a 
vicious  circle  is  only  prevented  from  continuation  ad 
infinitum  by  the  development  of  instinctive  compromises, 
viz.  somatic  episodes. 

It  is  a  well-known  clinical  fact  that  conscious  continual 
conflict  with  its  accompanying  distress  does  not  cause 
hysterical  episodes,  but  other  neuro-psychoses.  Never- 
theless suppression  does  play  a  part  in  the  aetiology  of 
other  conditions  than  hysteria.  Although  it  is  necessary 
for  the  production  of  the  hysterical  episode,  alone  it  is 
not  sufficient.  The  other  necessary  factor  that  is  here 
suggested  is  an  hyperexcitability  of  the  subconscious 
instinctive  ego. 

In  conclusion,  it  will  be  interesting  to  study  a  common 
type  of  shell-shock  in  the  light  of  this  theory. 

The  exact  pathogenesis  of  total  unconsciousness  result- 
ing from  trauma  to  the  head  or  atmospheric  concussion  is 


144    ATYPICAL  AND  COMBINED  PSYCHOSES 

obscure.  It  is  uncertain  if  the  unconsciousness  is 
associated  with  complete  inhibition  of  both  the  conscious 
and  subconscious  mind,  or  with  complete  inhibition  by 
the  censure  of  all  afferent  stimuli  to  consciousness. 
Hysteria  resulting  from  psychical  shock  not  producing 
unconsciousness  is  of  course  easily  explained  by  the 
hypothesis  enunciated  above.  Why  some  shell  shock 
cases  develop  hysteria  and  others  do  not,  is  not  yet 
determined.  Probably  a  considerable  proportion  of 
soldiers  in  action  have  of  necessity  to  suppress  the  fear 
complex,  because  it  is  too  insistent  and  severe  under 
certain  war  conditions  to  be  contemplated,  lest  its  kinetic 
tendency  should  become  too  strong  or  its  affective  tone 
cause  the  anxiety  neurosis  and  physical  signs  of  fear. 
Sublimation  is  difficult  as  anger  and  retaliation  in  trench 
warfare  except  when  the  men  "  go  over  the  top,"  or  in 
the  case  of  officers  in  the  responsible  distribution  of 
affairs.  Probably  the  relative  rarity  of  somatic  episodes 
in  officers  is  due  to  their  continual  sublimation  thus. 

One  explanation  (why  hysteria  occurs  inconstantly  in 
shell  shock)  is  that  it  is  possible  for  a  normal  person,  as 
the  result  of  continually  or  repeatedly  suppressed  severe 
emotional  complexes,  to  develop  the  hyperexcitability 
which  constitutes  the  hysterical  temperament ;  somatic 
episodes  would  then  result  from  any  special  stimulus 
e.  g.,  physical  or  psychical  trauma. 

In  favour  of  this  hypothesis  is  the  fact  that  such  trauma 
seldom  if  ever  produces  somatic  episodes  in  civil  life, 
except  in  the  case  of  recognized  hysterics. 

This  supposition  involves  the  presumption  that  soldiers 
who  develop  hysteria  after  shell  shock  have  been  subjected 
to  greater  strain  involving  more  pronounced  suppression. 

The  other  theory  is  that  shell  shock  hysteria  only  occurs 
in  soldiers  of  inherently  hysterical  temperament.  Such 
a  supposition  in  view  of  the  absence  of  all  history  of  pre- 


HYSTERIA  145 

war  hysteria  hardly  seems  justifiable,  but  it  must  be 
borne  in  mind  that  the  hysterical  temperament  only 
differs  from  the  normal  by  imperceptible  gradations.  It 
should  also  be  remembered  that  a  large  number  of  people 
of  so-called  hysterical  temperament  in  civil  life,  especially 
women,  never  develop  somatic  episodes  at  all. 

Briefly  outlined  on  p.  146  will  be  found  a  very  common 
case  of  shell  shock  with  hysteria  (together  with  explana- 
tions according  to  the  theory  I  have  endeavoured  to 
explain),  in  the  form  of  a  table,  A. 

The  numerals  refer  to  the  incidents  as  they  arise  chrono- 
logically in  the  course  of  the  affection,  those  distinguished 
by  added  strokes  indicating  alternative  conditions  : — 

Finally,  the  theory  of  the  hyperexcitability  of  the 
instinctive  subconscious  in  hysteria  can  be  explained 
also  in  terms  of  neurons,  that  is  to  say,  a  neurological 
description  of  the  mechanism  of  the  production  of  hys- 
terical episodes  is  possible  under  this  theory  and  in 
accordance  with  neuronic  theories.  Four  sets  of  neurons 
represent  the  four  stations  in  the  diagram  on  p.  147 
these  neurons  being  regarded  as  the  physical  basis  of  the 
functions  exhibited.  They  are  separated  by  synapses, 
one  of  which  represents  the  censure.  Beginning  at  the 
suppression ;  A  strong  current  of  nervous  energy  is 
transmitted  by  the  neurons  (E)  (physical  basis  of 
consciousness),  via  their  axons,  across  the  synapse  (D) 
to  the  dendrons  of  the  neurons  (C)  (subconscious  ego). 
This  transmission  occurs  according  to  neuronic  laws 
(actually,  of  course,  theories),  i.  e.,  simultaneously  with 
the  passage  of  energy  down  E's  axons,  occurs  the  retrac- 
tion of  the  gemmules  on  its  dendrons,  thus  cutting  off 
partially  and  transitorily  from  E  (consciousness)  the 
afferent  impulses  it  would  receive  via  its  dendrons  from 
the  axons  of  the  neurons  C  (the  subconscious).  The 
neurons  C  are  therefore  surcharged  with  energy  and  with 

e.m.d.  10 


146    ATYPICAL  AND  COMBINED  PSYCHOSES 


neurin,  but  in  the  case  of  normal  individuals,  such  sur- 
charge, although  denied  escape  through  C's  axon  to  E  via 

TABLE  A. 


"SHELL 
Z 
ATMOSPHERIC    OR 
TRAUMATIC    CONCUSSION- 
UNCONSCIOUSNESS 

is 

RETURN  OF  CONSCIOUSNESS 
ACCOMPANIED  BY  SEVERE  AFFECTIVE 
TONE.  OR  EMOTION  OF FEAR,  (PROBABLY 
DUE  TO  EFFECT  OF  SHOCK  ON  VASO- 
MOTOR SYSTEM  ETC  RESULTING  IN 
STIMULI  SUMMATING  WITH  PREVIOUS 
SUPPRESSED  FEAR  COMPLEXES  AND 
THUS  BREAKING  THROUGH  CENSURE). 


SHOCK 


FAILURE   TO  SUPPRESS   RESULTING 
IN  ANXIETY  NEUROSIS. 


.2' 
PSYCHICAL    SHOCK. 


*3' 

SEVERE  AFFECTIVE  TONE  OR  EMOTION 
(RESULT  OF  STIMULUS  OF  SHOCK 
5UMMA77NG  IN  THE  SAME  WAY). 


SUPPRESSimjf  FEAR  COMPLEX. 


WIDE  INHIBITION  BY  CENSURE 
CAUSING    STUPOR,    AUTOMATISM 
AMNESIA. 


NARROWING   OF  INHIBITION  BY  CENSURE  LEAVING 
ONE  OR  MORE  SOMATIC   HYSTERICAL  EPISODES.        <* 


7 

CHRONICITY/N 
ARMY(rARE) 


UNKAWRAL  RECOVERY  FROM  EPISODE, 
FROM  FRIGHTS,  TOO  EARLY  THERAPEUSIS 
(OFTEN  FOLLOWED  BY  FITS]  EMOTIONAL 
CRISESETC) 

ANXIETY    J/EUROSIS 

PARTIAL   RECOVERY,  PARTIAL 


NATURAL  RKOyERY  FROM  EPISODES 
THROUGH  FADING  OF  AFFECTIVE 
TONE  OF COMPLEX  (PERHAPS  AIDED 
BY  THERAPEUSIS  OR  DREAMS) 


CHRONicfrr 


(RETURNED  TO  DUTY)  RESUPPRESSION  ft  PSYCHASTHENIA)       (DISCHARGED  AS  UHFIT.) 


\ 


10 


,     EXTERNAL  STIMULUS  BY  ASSOCIATION  AROUSING  FEAR  COMPLEX  AGAIN. 
(EG.   THE  HAN  IS  PUT  DOWN  FOR  A  DRAFT,   OR   OLD  ASSOCIATIVE 

ENVIRONMENT   ACTS), 


RESUPPRESSION. 


RETURN  OF  SOMATIC 
EPISODE 


RELAPSE  INTO  ANXIETY  NEUROSIS;. 


FAILURE  OF  RESUPPRESSION,  RESULTING  IN 
EPILEPTIC  FITS    OR  DELIRIUM,  OH  HYSTERICAL  FITS. 
(SEE  CHAPTER    VII   "SHELL  SMOCK}. 


its  gemrnules  retracted  as  the  result  of    the  continual 
efferent  current  through  the  axon  of  E,  is  not  sufficient 


CONSTITUTIONAL  IMMORALITY 


147 


to  disorder  the  relationships  between  C  and  E.  But  if 
the  neurons  C  are  already  hyperexcitable,  i.e.,  surcharged 
with  neurin,  their  most  powerful  attempts  to  discharge 
their  energy  are  met  by  still  more  powerful,  undue, 
and  irregular  efferent  action  of  the  neurons  E.  (Over- 
action  to  stimuli.)  Other  gemmules  of  E  therefore 
normally  receiving  afferent  muscular,  sensory,  etc., 
peripheral  stimuli  are  more  or  less  permanently  retracted 
and  the  hysterical  somatic  episode  results.  Other 
effects  may  also  occur  from  the  penning  up  of  neurin 
in  excess  within  the  neurons  C,  viz.  disturbance  of  the  free 
afferent  flow  from  B,  and  hence  the  supervention  of 
vaso-motor  episodes. 

Further  afferent  stimuli  to  the  neurons  C  increase 
the  surcharge  of  neurin,  and  a  further  comparison  in 
power  of  energy,  afferent  and  efferent  respectively,  as 
regards  E,  occurs.  Should  the  former  be  stronger  than 
the  latter,  discharge  via  C's  axon  to  E  occurs,  the  synoptic 
resistance  at  D  (the  censure)  being  overcome,  and  the 
complex  reaches  consciousness  through  this  summation  of 
stimuli,  thus  curing  the  episode. 


SUBCONSCIOUS 

c 


LOWER  5EHS0RI 
MOTOR  NEUROHS 


VASO-HOTOR  AND 
SYMPATHETIC 

NEURONS 


PHYSICAL  BASIS  OF 
CONSCIOUSNESS 


SYNAPSE 

D. 
(censure) 


7.  CONSTITUTIONAL  IMMORALITY 

This  term  is  used  in  its  strict  sense  to  describe  an  inher- 
ent intrinsic  anomaly  resulting  in  continual  and  excessive 


148    ATYPICAL  AND   COMBINED  PSYCHOSES 

infraction  of  generally  recognized  moral  laws  on  the 
part  of  a  person  manifesting  no  intellectual  abnormality 
nor  any  other  sign  of  imbecility  or  psychosis. 

Probably  this  well-defined  conception  of  a  special 
anomaly  is  erroneous  ;  at  any  rate  there  is  little  evidence 
to  be  adduced  in  its  support. 

It  will  be  noted  that  in  order  to  be  covered  by  this 
definition,  criminals  and  immoral  persons  must  manifest 
excessive  deviations  from  the  moral  code  in  the  direction 
of  repetition  and  monstrosity.  And  this  proviso  gives 
away  the  whole  theory  of  a  sharply  defined  anomaly  of 
purely  moral  nature.  What  criteria  are  to  be  available 
to  enable  the  line  to  be  drawn  between  the  degrees  of 
immorality,  or  of  the  loss  of  control  or  lack  of  altruism 
which  may  be  setiological  factors  ?  We  are  none  of  us 
born  with  an  equal  tendency  towards  good  or  evil. 
Lack  of  moral  control  or  deficiency  of  altruism  may  be 
the  product  of  psychopathic  inheritance,  as  well  as  cir- 
cumstance, doubtless,  but  there  is  little  justification 
for  the  view  that  these  deficiencies  alone  (themselves 
relative)  constitute  a  psychopathic  state,  let  alone  an 
inherent  "  degenerative  anomaly."  Would  one  dare  to 
diagnose  any  psychopathic  state  or  anomaly  from  the 
relative  lack  of  one  trait  only  ?  It  may  be  conceded  that 
certain  individuals  inherit  an  excessive  impulsiveness  of 
character  or  a  degree  of  altruism  below  that  of  the  majority 
of  their  fellows,  but  if  this  is  to  be  regarded  as  of  anoma- 
lous or  pathological  significance  it  should  be  accompanied 
by  other  signs  of  psychopathic  inferiority.  One  does  not 
diagnose  ordinary  imbecility  from  the  absence  of  critical 
faculty,  for  example. 

A  large  proportion  of  the  chronic  immorals  and  crim- 
inals do  show  marked  signs  of  intellectual  and  emotional 
abnormality,  and  in  these  a  psychopathic  family  history 
is  common. 


CONSTITUTIONAL  IMMORALITY  149 

In  ordinary  criminals  or  insistently  immoral  persons 
who  show  no  signs  of  any  other  deviations  from  the 
normal  in  conduct  or  personality,  a  psychopathic  family 
history  is  no  more  common  than  in  law-abiding  persons. 
If  a  purely  moral  imbecility  exists  as  a  variety,  it  should 
be  possible  to  demonstrate  an  appropriate  family  history. 
As  a  matter  of  fact  in  many  descriptions  of  so-called 
purely  moral  imbeciles  which  one  reads,  other  signs  of 
obvious  abnormality  are  recorded,  and  as  evidence, 
ignored. 

From  the  study  of  chronic  criminals  as  we  find  them 
certain  facts  transpire. 

It  is  found  that  those  of  the  worst  type  are  often  definite 
psychopaths  such  as  chronic  alcoholics,  imbeciles,  and 
epileptics.  Others  are  paranoiacs,  hypomaniacs,  para- 
lytics (not  usually  sinners  of  long  standing)  slowly  develop- 
ing cases  of  dementia  prsecox,  or  normal  blackguards. 
In  passing,  it  may  be  said  that  Lombroso's  identification 
of  constitutional  criminality  with  epilepsy  is  untenable 
in  the  fight  of  modern  knowledge.  To  sum  up,  then,  the 
theory  of  the  specially  anomalous  nature  of  chronic 
immorality  apart  from  other  deviations  from  the  normal, 
is  not  only  unproved  but  improbable. 

One  word  concerning  the  treatment  of  cases  of  chronic 
immorality  and  crime.  Psychological  and  medical  treat- 
ment there  is  none  of  any  avail.  Hypnotism  with 
suggestion  can  sometimes  temporarily  cure  a  special 
case,  but  it  cannot  change  the  character  of  a  chronic 
criminal — the  vice  will  recur  or  merely  change  its  form, 
because  nothing  is  supplied  in  its  place.  Prisons,  moral 
teaching,  logical  reasoning,  and  environment  are  often 
perfectly  useless.  Criminal  conduct,  though  becoming 
a  habit,  is  a  subconscious  struggle  of  the  individual 
for  happiness — an  illicit  expression  of  an  instinct  present 
in  all  men.     It  is  quite  useless  to  take  away  the  means  of 


150    ATYPICAL  AND  COMBINED  PSYCHOSES 

expression  without  supplying  the  want  which  has  given 
rise  to  them.  To  change  a  chronic  criminal  into  a  good 
citizen,  it  is  necessary  for  him  to  be  "  converted,"  that  is 
to  say,  for  some  great  upheaval  of  his  personality  to  take 
place.  This  has  quite  commonly  been  brought  about. 
The  exact  pathogenesis  (if  such  a  word  may  be  pardoned) 
of  the  process  is  unknown,  but  the  aetiology  is  perfectly 
apparent,  viz.  first-hand  religion.  Those  who  are  inter- 
ested in  this  subject,  one  of  some  importance  to  the 
alienist,  should  get  into  touch  with  some  live  slum- 
working  religious  organization,  such  as  the  Salvation 
Army,  not  with  its  social  organizing  work,  but  its 
evangelical  missions  in  squalid  districts. 


CHAPTER  VII 

SHELL    SHOCK    (See  also    "Hysteria,"   p.   146,  Table  A,  for 
psychology  of  Shell  Shock.) 

(INCLUDING  BATTLE-STRAIN,  ETC.) 

The  notes  recorded  under  this  title  are  at  present  of 
necessity  somewhat  fragmentary.  There  is  as  yet  no 
co-ordinated  literature  available.  Each  observer  relates 
his  own  experience  ;  and  that  of  the  present  writer,  con- 
cerning cases  that  have  been  invalided  home,  many  of 
them  relapses,  or  first  attacks  arising  after  invaliding  for 
some  other  affection,  may  not  be  devoid  of  interest. 
The  cases  that  I  have  seen  were  those  from  the  Eastern 
Command  Depot,  Shoreham,  the  London  Command 
Depot,  Seaford,  as  well  as  those  from  ordinary  regimental 
depots,  etc.,  situated  in  the  Eastern  Command,  and  direct 
Expeditionary  cases  off  convoys. 

The  term  shell-shock  involves  no  definition,  but  is 
used  to  cover  practically  all  nervous  and  mental  manifesta- 
tions (and  also  their  generic  cause)  arising  as  the  result 
of  the  circumstances  of  battle.  It  embraces  in  the 
aetiological  sense  at  least  four  main  factors,  any  or  all  of 
which  appear  to  play  a  part  in  the  production  of  ner- 
vous or  mental  syndromes  : — 

1.  Physical  trauma  applied  to  the  head. 

2.  Atmospheric  concussion  following  large  explosions 
in  the  near  vicinity.  There  is  probably  (apart  from  gross 
injury)  no  essential  difference  in  the  effects  of  these  two 
causes. 

151 


152    ATYPICAL  AND   COMBINED  PSYCHOSES 

3.  Psychical  strain,  prolonged,  sudden,  or  both. 

4.  Injuries  in  regions  other  than  the  central  nervous 
system. 

5.  Neuropathic  inheritance. 

With  regard  to  immediate  effects,  the  following  sugges- 
tions appear  to  be  fairly  well  established. 

The  first  two  factors  usually  result  in  immediate  uncon- 
sciousness, which  may  be  followed  (and  occasionally 
replaced  in  less  severe  cases)  by  other  manifestations, 
e.  g.,  mental  confusion,  amnesia,  stupor,  etc. 

The  third  factor  would  appear  not  to  be  followed  by 
unconsciousness  (fainting  from  fright  being  excluded). 
Prolonged  steady  strain  usually  results  in  asthenic  pic- 
tures of  neurasthenia  ;  sudden  intense  strain,  in  acute 
mental  disturbances  (e.  g.,  amentia),  amnesia,  acute 
agitated  neurasthenia  (anxiety  neurosis),  hyste  ical 
dumbness,  etc.,  fits,  automatism,  and  partial  unconscious- 
ness. 

The  fourth  cause  is  seldom  operative  in  the  production 
of  immediate  nervous  or  psychical  disorder,  but  later 
secondary  manifestations,  though  rare,  do  occur  in  some 
cases.  Probably  the  wound  has  no  connexion  with  the 
shell-shock,  except  that  it  may  later  on  determine  the 
seat  of  an  hysterical  somatic  episode.     (See  Hysteria.) 

Marked  neuropathic  inheritance  or  acquired  (pre-war) 
instability  is  not  found  in  many  cases  other  than  those  of 
neurasthenia  resulting  from  general  steady  strain,  such 
being  sufficient  as  a  rule  to  cause  a  breakdown  in  these 
men. 

Of  course,  the  difficulty  of  the  whole  question  is  that 
the  vast  majority  of  cases — at  all  events  the  severe  types 
— have  been  subjected  to  many  or  all  of  the  above  factors. 

In  some  cases  (apart  from  unconsciousness  resulting 
from  causes  1  and  2 )  there  is  a  considerable  latent  period 
before  the  development  of  any  marked  nervous  symptoms 


SHELL-SHOCK  153 

at  all,  and  this  delayed  onset  is  not  confined  to  wounded 
men. 

A  common  history  of  cases  of  shell-shock  is  as  follows  : 

After  being  "  blown  up  "  in  some  degree,  or  following 
psychical  strain,  the  man  acquires  some  immediate 
psychical  or  nervous  symptoms  and  is  sent  into  hospital. 
Having  made  a  fairly  good  recovery,  he  is  sent  on  leave, 
and  subsequently  rejoins  a  regimental  or  command  depot. 
After  a  lapse  of  some  weeks  or  months,  he  again  breaks 
down,  often  with  symptoms  materially  differing  from 
those  for  which  he  was  originally  invalided. 

Another  class  of  case  is  that  in  which  the  man  has 
"  gone  sick  "  with  an  ordinary  medical  or  surgical  illness, 
and  develops  "  shell-shock "  after  recovery  from  the 
illness. 

Of  the  cases  that  break  down  with  shell-shock  at  the 
Front  and  completely  recover  without  being  sent  home,  I 
have  no  personal  experience. 

Finally,  there  is  the  man  who  develops  shell-shock 
at  the  front,  is  sent  home,  and  never  recovers  at  all, 
at  all  events  in  the  Service. 

The  latter  is  an  important  practical  point.  Unfortu- 
nately, the  shell-shocked  soldier  is  kept  in  military  hos- 
pitals and  convalescent  homes  for  months,  in  the  hope 
that  he  will  recover,  and  not  infrequently  eventually 
invalided  out  of  the  Service  as  unfit ;  when  if  he  were 
sent  home  to  his  people,  after  the  subsidence  of  acute 
symptoms,  say  in  a  couple  of  weeks,  he  would  recover 
a  thousand  times  more  rapidly,  and  subsequently  be 
quite  fit  for  some  form  of  military  service.  What  these 
cases  need  (I  am  not  of  course  referring  to  lunatics)  are 
their  homes  and  families  for  two  or  three  months,  then  a 
convalescent  home,  and  finally  a  Command  Depot. 
These  observations  are  especially  applicable  to  the 
fright  and  strain  types,  e.g.,  neurasthenia  of  all  sorts, 


154    ATYPICAL  AND  COMBINED  PSYCHOSES 

depressed  cases,  etc.,  to  whom  military  hospitals  are 
often  positively  harmful.  Acquired  neurasthenia  with 
agitation  and  depression  (anxiety  neurosis)  in  civil  life  is 
only  curable  by  removing  the  patient  for  a  while — in 
some  cases  permanently — from  the  environment  in  which 
it  arose.  The  Army  is  the  cause  of  shell-shock,  and  these 
men  should  be  removed  from  all  its  influences  for  a 
considerable  period.  If  they  relapse  seriously  when  they 
rejoin  they  will  never  be  any  use  in  it  again,  and  never 
would  have  been.  This  analogy  with  civilian  cases 
merely  strengthens  the  conclusions  arrived  at  from 
experience  of  soldiers  suffering  from  shell-shock,  in  a 
great  many  of  whom  the  syndromes  of  neurasthenia 
(both  forms),  psychasthenia,  emotional  depression,  and 
apprehension  of  neurasthenic  origin,  are  the  most  intract- 
able and  prominent  features. 

There  are  no  statistics  of  which  I  am  aware  to  show 
the  percentage  of  cases  of  shell-shock  that  relapse, 
or  who  develop  after  a  latent  period  nervous  symptoms 
following  bodily  illness,  or  psychopathic  and  neurotic 
manifestations  differing  from  the  original  shell-shock — 
but  it  must  be  a  high  one. 

It  is  mainly  with  these  similar  and  dissimilar  relapses 
that  these  present  notes  will  deal. 

The  following  cases  taken  at  random  from  those  who 
have  passed  through  my  hands  are  fairly  typical.  Com- 
ments on  them  will  be  made  subsequently.  The  events 
in  the  cases  are  recorded  chronologically  : 

Case  1. — Atmospheric  concussion  from  shell  explosion, 
October,  1915,  followed  by  unconsciousness. 

Blindness  for  a  month  immediately  following  recovery 
of  consciousness;  "neurasthenia"  (anxiety  neurosis) 
after  return  of  sight ;  partial  recovery  (i.e.,  apparently 
nearly  complete  recovery)  ;  latent  period  of  a  few 
weeks :   return    of    blindness    in   one   eye   (December) ; 


SHELL-SHOCK  155 

five  days'  automatic  wandering  (hysterical)  (the  man 
was  found  in  a  west  country  town  five  days  after 
leaving  home  to  rejoin  Depot  and  seen  by  an  R.A.M.C. 
M.O.  who  reported  that  he  was  dazed  and  amnesic  for 
that  period)  ;  admission  to  2nd  E.  G.  Hospital,  December 
15.  On  admission  was  found  to  be  suffering  from  minor 
hysterical  symptoms,  e.g.,  inability  to  open  his  eyes,  and 
to  see  clearly  when  the  fids  were  raised.  These  symptoms 
rapidly  cleared  up  under  suggestive  conversation,  and 
did  not  return.  Except  for  anaemia  and  slight  emotional 
depression,  he  remained  well  until  December  25.  On 
that  day  began  for  the  first  time  to  have  definite  epileptic 
fits  and  nocturnal  epileptic  delirium.  In  January  was 
discharged  as  an  epileptic.  There  was  no  epileptic 
temperament  or  feeble-mi ndedness .  Finally,  there  had 
never  been  any  personal  or  family  neuropathic  or  psycho- 
pathic history. 

Case  2. — Shell-concussion  ("  blown  up,"  precise  nature 
unknown),  April,  1915,  followed  by  unconsciousness ; 
subsequently  asthenic  neurasthenia,  pains  in  head,  and 
slight  amnesia.  Admitted  to  2nd  E.  General  in  January, 
1916.  On  admission  was  semi-conscious,  stupefied,  con- 
fused, and  disorientated,  having  no  idea  even  of  the  general 
nature  of  his  surroundings  or  companions.  He  was  not 
apprehensive  ;  hallucination  seemed  to  be,  and  flight  of 
ideas  was,  absent.  He  appeared  anxious  in  a  dull  sort 
of  way,  continually  expecting  "  a  sailor  with  a  card." 
His  mind  ran  on  this  topic  alone,  and  his  speech,  though 
fragmentary  and  infrequent,  was  perfectly  intelligible 
and  showed  his  evident  train  of  thought.  He  gave  no 
replies  when  questioned,  but  obeyed  such  simple  com- 
mands as  he  could  understand.  He  appeared  to  be  am- 
nesic, and  his  mental  action  was  obviously  slow  and 
laboured.  In  short,  his  condition  was  almost  a  typical 
epileptic  confusional  attack. 


156    ATYPICAL  AND  COMBINED   PSYCHOSES 

Three  days  later  he  emerged  from  his  delirium,  and 
except  for  amnesia  for  the  attack  and  some  degree  of 
general  mental  retardation,  remained  normal  until  trans- 
ferred. No  signs  of  the  epileptic  temperament  were 
manifest.     Personal  and  family  history  negative. 

Case  3. — Delirium  due  to  strain  of  action  :  "  neuras- 
thenia "  followed  :  apparently  complete  recovery  (that 
is,  latent  period)  for  three  months.  Then  epileptic  fits 
supervened.  There  were  no  signs  of  the  epileptic  tempera- 
ment. Physical  and  family  psychopathic  history  nega- 
tive. 

Case  4. — Buried  in  mine  explosion,  October,  1915. 
Subsequent  unconsciousness  or  semi-conscious  for  several 
days.  After  recovery  from  that,  was  "  neurasthenic  " 
and  exhibited  functional  deafness  and  stammer.  Then 
followed  actual  mutism  for  several  weeks.  Next  the 
dumbness  disappeared,  and  epileptic  fits  supervened. 

On  admission,  he  was  in  a  waking-dream-like  con- 
dition (hysterical),  completely  disorientated,  inacces- 
sible, and  anaesthetic  to  pin-pricks.  He  lay  in  bed 
dumb,  with  a  grave  awe-struck  expression  on  his  face, 
watching  and  following  with  his  finger  the  flight  of 
hallucinatory  aeroplanes.  Flexibilitas  cerea  was  pro- 
nounced. There  was  no  oppressive  stupefaction.  The 
following  day  he  had  emerged  and  merely  manifested 
some  slowness  in  mental  action,  disorientation  in  time, 
complete  amnesia  from  the  attack,  and  some  defect  of 
associative  memory.  The  stammer  had  returned.  The 
day  after  that,  only  amnesia  for  the  attack  remained. 
Finally  he  began  once  more  to  have  epileptic  fits.  The 
man's  previous  history  was  important.  Thirteen  years 
ago  he  had  a  fit  for  the  first  time  in  his  life,  and  since 
had  had  a  few  more.  Seven  years  ago  he  had  suffered 
from  "  a  stroke,"  and  it  was  found  that  slight  hemi- 
plegia was  still  present. 


SHELL-SHOCK  157 

Case  5. — Wounded  in  leg,  and  several  months  after- 
wards developed  "  neurasthenia,"  followed  by  complete 
recovery.  A  latent  period  of  about  three  months  occurred 
next,  at  the  end  of  this  epileptic  fits  supervened,  and  the 
man  was  discharged.  No  epileptic  temperament  or 
equivalents  were  observed.  Previous  history  and  family 
history  were  negative. 

Case  6. — Atmospheric  shell  concussion,  November, 
1915  ;  not  followed  by  unconsciousness,  but  a  few  hours 
afterwards  by  automatism — succeeded  by  amnesia.  Sub- 
sequently was  "  neurasthenic  "  for  some  months.  Appar- 
ent recovery  followed  until  March,  1916,  when  epileptic 
fits  began.  No  epileptic  temperament.  No  psycho- 
pathic history. 

Case  7. — "  Blown  up  "  by  a  bomb  and  became  un- 
conscious. Acute  anxiety  neurosis  followed,  from  which, 
after  five  months  in  various  hospitals,  the  man  never 
recovered  while  in  the  Service.  Personal  history  of 
timidity  and  psychasthenia. 

Case  8. — Severe  wound  in  back  ;  bullet  eventually 
located  and  removed  two  months  afterwards.  Five 
months  after  wound,  developed  nocturnal  delirium. 
Three  weeks  later  a  typical  attack  of  epileptic  confusion 
lasting  about  a  week.  This  began  by  an  explosion  of 
temper  and  violence,  succeeded  by  a  picture  of  slow 
stupefied  confusion  and  depression,  with  vindictiveness 
and  ideas  of  ill-usage  alternating  with  tears.  Amnesia 
for  incidents  of  attack  remained.  Subsequently  more 
or  less  periodical  depression  of  short  duration,  causeless 
and  unaccompanied  by  neurasthenic  signs,  manifested 
itself.  A  definite  epileptic  temperament  was  present. 
The  former  history  revealed  night-terrors  in  childhood, 
occasional  nocturnal  tongue-biting  in  adult  life,  but  no 
known  fits. 

The    above    examples,    though   individual    cases,    are 


158    ATYPICAL  AND  COMBINED  PSYCHOSES 

types,  many  essentially  similar  having  been  seen.  Simple 
cases  of  asthenic  neurasthenia  without  mental  anxiety  or 
hysterical  symptoms  were  seldom  admitted  to  my 
wards. 

In  the  types  of  cases  illustrated  by  the  above  examples, 
certain  interesting  features  are  to  be  observed. 

1.  The  first  point  that  strikes  one  is  the  frequent 
development  of  epileptic  fits  or  equivalents  in  cases  of 
severe  shell-shock. 

2.  The  next  is  the  fact  that  in  many  cases  a  latent 
period  of  apparent  health,  varying  from  a  few  weeks 
to  several  months,  preceded  the  development  of  the 
fits. 

3.  The  intermixture  and  succession  of  hysterical, 
neurasthenic  anxiety  and  epileptic  features  in  a  single 
case  is  very  common,  in  fact  almost  the  rule. 

4.  The  absence  in  nine  out  of  ten  of  these  shell-shock 
epilepsies  of  the  epileptic  temperament. 

The  following  comments  upon  these  four  observations 
are  intended  to  be  suggestions,  not  dogmatic  assertions  : 

1.  The  common  incidence  of  epileptic  fits  as  a  result 
of  shell-shock  in  persons  previously  showing  no  signs  of 
psychopathic  tendency  or  heredity,  would  appear  to 
put  the  final  nail  in  the  coffin  of  the  theory  of  the  degen- 
erative and  inevitably  hereditary  nature  of  fits.  Trau- 
matic epileptic  fits  in  civil  life,  intoxication  epileptic 
fits,  etc.,  were  other  nails.  Other  interesting  points 
concerning  epilepsy  are  also  brought  to  fight  by  the 
study  of  these  shell-shock  cases :  one  of  which  is 
that  atmospheric  concussion  may  apparently  cause 
epileptic  fits  ;  another  is,  that  even  specific  shell-con- 
cussion is  not  essential  in  these  cases,  fits  resulting  in 
some  men  without  any  shell-explosion  having  occurred 
in  their  very  near  neighbourhood.  Cases  3  and  5  illus- 
trate  these   points.     Examples   of   this   class   do   more 


SHELL-SHOCK  159 

than  suggest  that  epileptic  fits  may  result  from  psychical 
trauma  alone.  The  theory  held  by  the  present  writer, 
that  these  fits  are  identical  in  aetiology  and  pathogenesis 
with  hysterical  fits  is  discussed  under  "  hysteria." 

2.  In  cases  of  traumatic  hysteria  and  "  neurasthenia  " 
the  frequency  of  a  latent  period  following  the  immediate 
shock  of  the  trauma  is  well  recognized,  but  it  would 
appear  that  a  period  of  incubation  very  frequently  if  not 
in  every  case  precedes  the  development  of  fits  in  shell- 
shock  epilepsy.  It  may  be  contended  that  masked 
epilepsy  was  in  existence  throughout  this  latent  period, 
and  even  from  the  period  immediately  following  the 
trauma,  but  how  this  contention  is  to  be  maintained  in 
the  absence  of  all  signs,  it  is  difficult  to  see.  It  is  true 
that  vertigo  precedes  the  fits  for  some  time  in  a  few  cases. 
But  vertigo  is  an  exceedingly  common  feature  in  shell- 
shock  of  all  varieties,  and  in  only  a  few  is  it  followed  by 
convulsions.  The  same  observations  are  true  of  tran- 
sitory muddled  feelings  in  the  head,  depression,  etc., 
and  I  do  not  think  one  is  justified  in  regarding  all  these 
symptoms  as  epileptic  manifestations.  However  that 
may  be,  there  is  a  considerable  residue  of  cases  which 
never  manifest  any  of  these  signs  of  masked  epilepsy,  if 
such  they  be,  but  begin  ?  after  a  period  of  apparent  health, 
to  suffer  from  fits. 

In  cases  of  physical  or  atmospheric  concussion  followed 
by  unconsciousness,  the  delay  in  the  onset  of  the  fits 
may  possibly  be  explained  by  the  supposition  of  cica- 
trices, organization  of  blood-clot,  etc.  ;  but  it  is  not  easy 
to  see  how  the  psychical  strain  epilepsies  are  susceptible 
of  this  explanation. 

It  is  probable  then,  as  suggested  above,  that  in  a  case 
of  epileptic  fits  instituted  by  psychical  strain  (and 
arguing  also  from  analogy  with  traumatic  hysteria) 
that  the  epileptic  fit  itself  may  be  primarily  a  psychical 


160     ATYPICAL  AND   COMBINED  PSYCHOSES 

commotion  differing  in  appearance  but  not  in  essence 
from  the  ordinary  hysterical  fit. 

This  and  other  hypotheses  arising  out  of  such  cases 
must  for  the  present  remain  hypotheses. 

3.  There  is  nothing  remarkable  in  the  coincidence  of 
succession  of  the  various  neurotic  and  psychical  results  of 
shell-shock  in  a  single  case,  when  one  views  them  in  the 
light  of  the  theories  propounded  above  under  "  Hysteria  " 
(vide  p.  135  et  seq.)  and  under  "  psychasthenia"  (p.  128). 
Psychical  trauma  would  appear  to  be  the  most  potent  fac- 
tor in  the  production  of  all  but  the  immediate  loss  of  con- 
sciousness following  actual  concussion.  Simple  concussion 
in  civil  life,  when  it  is  not  accompanied  or  followed  by 
psychical  trauma,  rarely  results  in  neuroses  or  psychoses 
or  fits.  It  is  not  unlikely  that  where  such  do  supervene 
evidence  of  psychopathic  inferiority  always  pre-exists. 
Battle-strain,  although  perhaps  not  consciously  and 
fully  recognized,  is  a  severe  form  of  unhappiness.  The 
importance  of  unhappiness  is  coming  to  be  more  and 
more  recognized  in  its  relation  to  nervous  and  mental 
health.  No  single  cause  conduces  so  much  to  the  develop- 
ment of  psychoses  and  neuroses.  The  struggle  of  the 
individual  for  happiness  is  the  struggle  of  the  individual 
for  health,  and  the  loss  of  the  one  involves  eventually 
the  loss  of  the  other. 

4.  The  absence  of  the  epileptic  temperament  or  char- 
acter in  so  many  of  these  shell-shock  epilepsies,  even 
after  the  fits  have  become  well  established,  is  interesting, 
and  it  can  be  interpreted  in  three  ways.  One  view  that 
may  be  held  is  that  the  fits  have  not  existed  long  enough 
for  the  character  to  develop.  This  supposition  pre- 
supposes that  the  temperament  is  the  result  of  the  fits. 
I  know  of  no  statistics  as  to  the  ultimate  development 
of  the  temperament  in  the  traumatic  epilepsies  of  civil 
fife,  and  our  experience  of  shell-shock  cases  has  not  been 


SHELL-SHOCK  161 

long  enough  to  justify  any  deduction  from  them  on  this 
head.  Nevertheless,  in  view  of  certain  considerations  I 
do  not  think  this  hypothesis  is  the  right  one.  The 
epileptic  temperament  is  found  in  persons  who  have  not 
developed  fits,  but  who  subsequently  do  so,  and  also  in 
cases  of  masked  epilepsy  without  convulsions.  Again 
one  finds  that  in  a  considerable  proportion  of  shell- 
shock  epilepsies,  which  do  manifest  the  character,  evi- 
dence of  the  preexistence  of  the  latter  can  be  obtained, 
and  signs  of  masked  equivalents  in  some  cases.  Why 
these  cases  should  have  developed  the  temperament  as 
the  result  of  fits,  and  the  much  larger  number  should  not 
have  done  so,  it  is  difficult  to  explain,  if  such  a  theory  is 
correct. 

Another  explanation  of  the  rarity  of  the  epileptic 
temperament  in  shell-shock  epileptic  fits  is  that  the 
temperament  is  inherent. 

The  present  writer  regards  it  simply  as  a  special  variety 
of  psychopathic  inheritance  indicating  a  strong  pre- 
disposition to  the  development  of  fits  and  equivalents. 
Persons  of  epileptic  temperament,  in  other  words,  have 
a  psychopathic  family  history,  often  dissimilar  in  type, 
but  the  temperament  and  its  accompanying  tendencies 
shades  off  into  the  normal  in  different  individuals.  The 
well-marked  cases  usually  develop  fits,  the  less  marked, 
often  masked  equivalents — both  more  or  less  spontan- 
eously. Considerable  emotional  upheaval  or  physical 
trauma  causing  organic  lesions  or  toxic  infection  is 
necessary  to  the  production  of  fits  in  persons  without 
perceptible  epileptic  temperament.  It  is  not  unlikely 
that  the  temperament  is  also  an  essential  factor  in 
the  development  of  all  "  insane "  epileptics,  that 
is  to  say  those  in  whom  psychical  equivalents  are 
pronounced  and  in  whom  dementia  develops.  It  is 
well  known   in    the    case    of    epileptic    feeble-minded- 

e.m.d.  1] 


162    ATYPICAL  AND  COMBINED  PSYCHOSES 

ness  that  its  intensity  is  dependent  upon  the  age 
incidence  of  the  fits,  and  naturally  one  would  expect 
those  persons  with  a  marked  predisposition  thereto 
to  develop  the  fits  early  in  life.  This  suggestion  explains 
also  why  the  temperament  is  in  fact  found  most  marked 
in  chronic  convulsive  cases.  Probably,  however,  the 
traits  in  the  character  are  intensified  by  the  inequality 
of  the  struggle  for  existence  to  which  severe  types  are 
subjected,  as  compared  with  those  less  seriously  affected 
and  the  normal ;  moreover  the  patient's  control  and 
judgment  are  weakened  by  the  progress  of  the  feeble- 
mindedness, hence  the  traits  of  the  temperament  are  less 
concealed. 

The  third  view  is  that  the  epileptic  temperament  is 
absent  because  the  fits  in  shell-shock  are  in  origin  hys- 
terical. 

A  great  deal  that  we  have  learnt  from  the  results  of 
shell-shock  was  previously  known  in  association  with 
other  traumatic  causes,  and  in  concluding  these  brief 
notes  it  will  be  as  well  to  quote  in  abridged  fashion  from 
a  standard  author  i1 

"...  A  fairly  typical  series  of  traumatic  insanities 
is  now  known,  having  as  a  common  feature  impairment 
of  the  memory  and  character.  The  various  clinical  pic- 
tures that  result,  more  especially  in  cases  in  which  the 
trauma  has  affected  the  head,  are  as  follows  : 

"1.  Ephemeral  or  partial  disturbances  immediately 
succeeding  the  traumatism,  such  as  loss  of  consciousness 
together  with  anterograde  and  retrograde  amnesia. 

"2.  Chronic  psychoses  (chiefly  hysterical  in  nature) 
after  a  latent  period  and  which  are  rarely  recovered  from. 

"  3.  Special  and  irreparable  perversions  of  character. 

"  4.  Reflex  psychoses,  hypochondria,  mono-hysteria 
and  epilepsy  consequent  upon  compression  and  irritation 
xTanzi,  Text  Book  of  Mental  Diseases,  1909. 


SHELL-SHOCK  163 

of  the  nerve  tracts  or  upon  trauma  affecting  other  parts 
of  the  body  than  the  head  and  brain." 

I  think  we  have  got  a  little  farther  than  this  summary. 
Considerations  of  space  preclude  lengthy  criticism  here — 
it  is  left  to  the  reader — but  one  would  appear  to  be 
justified  in  saying  that  the  terms  "  insanity  "  and  "  psy- 
choses "  at  least  are  used  rather  too  loosely. 

With  regard  to  the  association  of  other  mental  dis- 
orders with  the  causes  of  shell-shock,  it  may  be  said 
that  ordinary  mental  affections  would  appear  to  be  un- 
common amongst  delayed  or  relapsed  syndromes.  They 
are,  I  believe,  more  common  at  the  Front,  and  take  the 
usual  form  of  amentia,  mania,  and  melancholia.  Of 
those  of  delayed  onset  the  most  frequent  to  appear  is 
dementia  prsecox,  probably  owing  to  the  relative  youth 
of  the  majority  of  our  soldiers  (until  recently).  Melan- 
cholia and  confusional  attacks  sometimes  supervene 
upon  active  service  "  neurasthenia  "  (combined  type). 

To  sum  up,  the  present  writer  regards  the  following 
conclusions  drawn  from  the  study  of  shell-shock  as 
provisionally  accurate.  Agitated  neurasthenia  (anxiety 
neurosis)  in  these  cases  is  due  to  continued  or  repeated 
conscious  conflict  between  the  fear  complex  and  environ- 
ment or  higher  control,  and  is  accompanied  by  a  process 
of  auto-intoxication.  It  may  or  may  not  have  been 
preceded  by  hysterical  episodes,  but  previous  suppression 
of  the  complex  has  always  preceded  its  development. 
The  neurosis  is  likely  to  be  more  severe  where  the  environ- 
ment tends  to  necessitate  further  attempts  at  suppression 
of  the  fear  complex,  which  fail.  Persons  who  are  con- 
stitutionally fearful  in  temperament  (psychasthenics) 
more  readily  develop  the  anxiety  neurosis. 

Suppression  of  the  fear  complex  in  persons  of  hysterical 
temperament   (probably  existing  in  previously  normal 


164    ATYPICAL  AND   COMBINED  PSYCHOSES 

persons  after  continued  and  repeated  suppression)  results 
in  hysterical  "stupor,"  automatism,  or  somatic  episodes. 

Fits  occurring  after  a  latent  period,  which  have  never 
been  preceded  by  any  signs  of  epilepsy  prior  to  the  shell 
shock,  and  which  are  not  accompanied  by  the  epileptic 
temperament  or  due  to  gross  injuries  to  the  skull,  are 
the  result  of  sudden  transitory  and  violent  failure  of 
suppression  of  the  fear  complex,  and  are  essentially 
hysterical  in  mechanism  whatever  their  clinical  character 
may  be. 

"  Epileptic  "  delirium  in  these  cases  is  of  similar  nature 
to  hysterical  delirium. 

There  would  appear  to  be  two  distinct  forms  of  epileptic 
fits,  apart  from  those  due  to  organic  irritative  cerebral 
lesions — distinct,  that  is,  in  aetiology  and  mechanism  of 
production. 

1.  True  idiopathic  epilepsy  accompanied  by  the 
epileptic  temperament,  and  tending  to  dementia.  A 
family  history  of  insanity  or  epilepsy  is  forthcoming 
in  these  cases,  and  they  are  usually  incurable. 

There  are  of  course,  owing  to  the  fact  that  the  epileptic 
temperament  shades  off  into  the  normal  in  different 
persons,  grades  of  tendency  to  idiopathic  fits.  These 
grades  would  account  for  temporary  epilepsy  due  to 
metabolic  disturbances,  rickets,  teething,  trauma  not 
involving  continued  organic  irritation,  etc. 

2.  Epileptic  fits  of  hysterical  origin  unaccompanied  by 
the  epileptic  temperament,  and  not  tending  to  dementia 
in  their  subjects.  In  them  no  history  of  insanity  or 
epilepsy  in  the  family  is  obtainable,  and  they  are  some- 
times, probably,  if  pure  cases,  always  curable. 

It  will  be  easily  seen  that  fits  of  combined  origin  may 
occur,  the  hysterical  mechanism  of  suppression  and 
hyperexcitability,  acting  as  an  exciting  cause  to  some 
degree    of    epileptic    temperament.     This    is    probably 


SHELL-SHOCK  165 

the  explanation  of  occasional  chronicity  in  fits  of  shell- 
shocked  soldiers  after  discharge  from  the  Army,  and 
probably  also  of  fright,  etc.,  epilepsy  in  civil  life,  but  it 
it  is  also  probable  that  continual  repetition  of  fits  of 
hysterical  origin  may  terminate  under  unfavourable 
conditions  in  chronic  epileptic  fits  as  the  result  of  cere- 
bral habit,  in  the  case  of  persons  never  perceptibly  of 
epileptic  temperament.  With  regard  to  clinical  distinc- 
tions between  the  two  varieties  of  individual  epileptic 
fits,  it  may  be  said  at  once  that  there  does  not  appear 
to  be  any  in  a  considerable  number  of  cases. 

The  distinctions  between  typical  hysterical  (old  classical 
type)  convulsions  and  typical  epileptic  fits,  are  of  course 
well  known.  In  the  post-convulsive  or  equivalent  hys- 
terical states  of  delirium  there  is  this  distinction  from 
those  of  chronic  epilepsy,  namely  the  patient  is  not  so 
stupefied,  his  mental  action  is  more  rapid,  and  he  is  more 
accessible  to  external  stimuli. 

True  hysterical  delirium  apart  from  convulsions  is 
marked  by  a  complete  absence  of  stupefaction  but 
complete  dissociation  from  the  environment.  All  hys- 
terical emotional  states  of  dissociation  being  of  the 
nature  of  vicarious  expressions  of  instinct  suppressed, 
illustrate  the  instinct. 

Hysterical  "  stupor  "  and  automatism  manifest  less 
inaccessibility  and  imperception  than  similar  epileptic 
states. 

Fits  that  are  periodical  are  always  at  least  in  part  due 
to  idiopathic  epilepsy. 

Finally,  after  shell-shock,  chronic  epileptics  not  infre- 
quently develop  fits  of  definite  hystero-epileptic  type. 


CHAPTER  VIII 

COMBINED  AND  ATYPICAL  PSYCHOSES 

The  study  of  mixed  mental  disorders  is  as  interesting 
as  it  is  complex.  It  is  as  yet  in  its  infancy,  but  by  the 
record  of  individual  cases  a  literature  relating  to  the 
subject  can  be  built  up  for  subsequent  students  to  sys- 
tematize and  correlate. 

Several  varieties  have  been  mentioned  already  ;  in 
this  chapter  they  will  be  supplemented,  grouped  together, 
and  briefly  summed  up  in  a  provisional  fashion,  the 
accuracy  of  the  epitome  so  far  as  designation  is  concerned 
being  dependent  upon  our  present  knowledge  and  plausi- 
ble theories  of  classification. 

Three  main  groups  of  cases  present  themselves  for 
examination,  viz.  : 

1.  Combinations  of  anomalies  with  psychoses  or 
neuroses. 

2.  Combinations  of  anomalies  with  anomalies. 

3.  Combinations  of  psychoses  and  neuroses  with  each 
other. 

1.  COMBINATIONS    OF   ANOMALIES    WITH 
PSYCHOSES  AND  NEUROSES 

By  the  term  an  anomalous  person  is  meant  one  whose 
abnormality  is  an  inherent  integral  part  of  his  ego,  and 
not  an  acquired  disorder.  Anomalies  are  not  monstros- 
ities— wretched  individuals  born  outside  the  pale  of  the 

166 


COMBINED  AND  ATYPICAL  PSYCHOSES     167 

rest  of  humanity — but  simply  people  whose  inherent 
deviation  from  the  normal  type  is  pronounced.  Natur- 
ally enough  their  family  histories  are  psychically  more 
defective. 

In  this  sense  all  abnormal  temperaments  are  anomalies, 
and  probably  many  of  us  are  more  or  less  anomalous. 
Is  is  the  old  question  of  degree  of  abnormality,  and  there 
is  no  hard  and  fast  line  to  be  drawn. 

The  conditions  usually  described  as  anomalies  are 
paranoia,  imbecility,  and  constitutional  immorality. 
The  paranoical  temperament  is  a  marked  one  and  hence 
an  "  anomaly,"  the  development  of  delusions  in  such  cases 
being  analogous  to  the  development  of  fits,  etc.,  in 
persons  of  epileptic  temperament — probable,  but  not 
necessary  and  inevitable. 

Perhaps  the  best  conception  of  an  anomaly  is  an 
inherent  purely  psychical  deviation  from  the  normal. 
So  far  as  our  present  knowledge  points,  hysteria,  psych- 
asthenia  and  paranoia,  only,  would  be  covered  by  this 
definition. 

Imbecility  is  more  than  a  temperament  or  character, 
the  result  of  deviations  in  degree  of  prominence  or  dis- 
order of  fully  developed  faculties  ;  it  is  a  spontaneous 
arrest  of  development  of  all  faculties  recently  acquired 
by  man.  The  temperament  and  the  character  of  indivi- 
dual imbeciles  varies  just  as  that  of  individual  children, 
grown-up,  uneducated  varieties  of  which,  imbeciles  are. 
Children  can  be  educated  because  they  gradually  develop 
faculties  susceptible  of  education ;  imbeciles  do  not. 
Hence  the  final  difference  in  the  results. 

Constitutional  immorality  apart  from  imbecility  has 
been  discussed  on  page  147,  and  the  view  expressed  there 
that  the  existence  of  such  as  a  hard  and  fast  abnormality 
of  inherent  type  is  not  proven. 

Nevertheless  these  three  conditions,  one  in  essence  a 


168    ATYPICAL  AND  COMBINED  PSYCHOSES 

temperament,  another  an  arrest  of  development,  and  the 
third  a  simple  and  special  exaggeration  of  conduct,  are 
for  purposes  of  convenience  in  subdivision  included  in 
this  section  under  the  head  of  anomalies. 

(A)     ASSOCIATION     OF     PSYCHOSES     AND     NEUROSES 
WITH  IMBECILITY 

Imbeciles  are  more  liable  to  attacks  of  psychoses 
than  are  normal  persons,  but  the  varieties  of  mental 
disorder  do  not  materially  differ  in  the  two  cases. 

Perhaps  the  most  common  superimposed  mental 
syndromes  found  in  imbeciles  are  simple  stupor,  amential 
apprehensive  confusional  episodes,  epileptic  fits,  hysterical 
episodes,  and  depression. 

Simple  stupor  in  imbeciles  is  characterized  by  the 
absence  of  symptoms  of  the  specialized  stupors,  viz., 
katatonia,  emotional  depression,  or  epileptic  moods  and 
episodes,  etc.,  and  by  the  presence  either  of  demonstrable 
signs  of  imbecility  in  slight  cases  of  stupor,  or  marked 
intellectual  alienation  and  apparent  dementia  out  of  all 
proportion  to  the  degree  of  inaccessibility,  in  severe  cases. 
In  all  cases  the  "  demential  "  symptoms  are  much  more 
marked  in  proportion  to  the  inaccessibility  than  is  the 
case  in  simple  amentia  attonita.  Put  more  colloquially, 
the  patients  are  usually  without  ideas  or  memory,  lost 
in  mind,  vacant  and  dirty,  yet  quite  capable  of  under- 
standing ordinary  commands  and  of  appreciating  the 
nature  of  individual  objects.  There  is  less  general 
mentation  than  in  the  simple  stupor  of  dementia  prsecox  ; 
delusions,  hallucinations  (usually),  and  the  self -puzzled 
state  of  dementia  precox  are  absent.  Nevertheless  in 
minor  degrees  of  imbecility  with  stupor  the  distinction 
is  often  difficult. 

These  attacks  are  usually  short  in  duration,  but  occa- 
sionally persist  for  some  weeks,  not  infrequently  with 


COMBINED  AND  ATYPICAL  PSYCHOSES     169 

remissions.  They  are  not  accompanied  by  marked 
cachexia  even  when  prolonged.  They  are  probably 
amential  episodes  of  atonic  variety,  the  divergencies 
from  amentia  attonita  being  due  to  the  imbecility  on  the 
one  hand  and  to  the  generally  remarkably  good  bodily 
health  of  imbeciles  on  the  other. 

The  excited  amential  attacks  of  imbeciles  are  also 
short  in  duration,  and  differ  from  simple  agitated  amentia 
in  the  same  way  that  the  stuporose  attacks  differ  from 
amentia  attonita,  viz.  :  in  the  relatively  high  degree  of 
disorder  in  ideation,  association  and  reasoning,  to  the 
depth  of  inaccessibility.  They  evince  ephemeral  super- 
ficial and  childish  emotional  states  which  betray  their 
immaturity,  and  they  are  more  degraded  in  conduct  in 
relation  to  the  depth  of  confusion. 

In  addition  to  these  well-defined  states,  intermediate 
ones  are  found  with  a  mood  of  hilarity  and  exaltation,  or 
depression  and  tears,  both  accompanied  by  hallucinations 
and  confusion,  without  imperception  or  inaccessibility. 
Probably  these  are  analogous  to  paranoidal  amentia 
in  normal  persons,  the  absence  of  delusions  being  due 
to  the  imbeciles'  lack  of  imagination. 

Two  varieties  of  association  between  imbecility  and 
epilepsy  have  been  observed,  but  probably  one  of  them 
is  the  result  of  a  misconception. 

In  the  first  combination  the  fits  are  of  long  standing. 
There  is  a  general  lack  of  knowledge  and  a  considerable 
degree  of  childishness  both  intellectually  and  emotionally, 
but  replacing  the  alertness,  rapid  mental  action,  good 
memory  for  facts,  quick  perception,  volatility  and  conceit 
of  the  imbecile,  are  manifest  the  signs  of  the  epileptic 
temperament  and  feeble-mindedness. 

In  these  cases  one  is  dealing  with  an  organic  cerebro- 
pathy  accompanied  by  epilepsy. 

Theoretically  it  is  possible  for  a  person  of  epileptic 


170    ATYPICAL  AND  COMBINED  PSYCHOSES 

temperament  and  suffering  from  fits  to  be  also  an  imbecile. 
Possibly  some  of  the  long  standing  epilepsies  with  child- 
ishness, fickle  spitefulness  and  cruelty  are  of  this  mixed 
type. 

The  other  type  of  case  is  that  of  the  typical  imbecile 
who  suffers  from  more  or  less  infrequent  fits,  arising  at  a 
later  period  in  life.  This  association  is  probably  as 
accidental  as  it  is  uncommon. 

Imbeciles  who  grow  up  into  adolescent  dements  (their 
usual  method  of  developing  dementia  prsecox)  rapidly 
sink  into  a  depth  of  dementia  unknown  in  the  uncom- 
plicated psychosis,  and,  owing  to  their  lifelong  poverty 
of  ideas  and  lack  of  imagination,  they  present  a  relatively 
colourless  clinical  picture.  Katatonia  if  present  usually 
takes  the  form  of  stereotypism  of  a  simple  variety. 
Neologisms,  pedantry,  absurd  pseudo-scientific  delusions, 
and  the  generally  flowery  but  useless  ideation  and  con- 
versation of  dementia  prsecox,  are  absent  in  cases  where 
a  moderate  or  high  degree  of  imbecility  pre-existed. 
Comprehension,  orientation,  association  of  ideas  gener- 
ally, are  also  more  deeply  affected  in  the  combined 
cases. 

The  result  is  a  dirty,  automatically  destructive, 
degraded  and  useless  dement.  He  is  a  familiar  figure  in 
asylums,  frequently  to  be  perceived  picking  at  his  skin 
and  clothes,  and  emitting  animal-like  unintelligible 
noises,  while  lurking  in  all  the  glory  of  a  saliva-stained 
"  strong  suit  "  in  the  corner  of  an  airing  court — a  pitiable 
picture  of  the  degeneration  of  an  individual  to  a  level 
below  that  of  the  brutes. 

Like  ordinary  people  imbeciles  are  liable  to  attacks 
of  mania  and  melancholia,  but  not  nearly  so  strongly 
as  they  are  to  dementia  prsecox.  Manic-depressive 
syndromes  in  imbeciles  are  for  the  most  part  short  in 
duration,  and  characterized  by  an  easily  recognized  com- 


COMBINED  AND  ATYPICAL  PSYCHOSES      171 

bined  picture  of  symptoms.  Chronic  hypomania  may 
also  be  combined  with  imbecility.  This  class  of  patient 
is  to  be  distinguished  from  uncomplicated  hypomania 
by  the  general  futility  of  conduct,  childishness,  and  lack 
of  principle,  knowledge,  and  imagination  displayed. 

Some  imbeciles  suffer  from  attacks  of  noisy  lachrymose 
depression  quite  frequently,  but  the  attack  passes  off  in 
a  day  or  two.  Probably  these  are  not  of  manic-depressive 
origin. 

Hysterical  episodes  are  common  in  imbeciles,  but 
the  more  elaborate  varieties  are  probably  impossible 
to  them.  The  common  manifestations  are  fits  and 
emotional  crises. 

Alcoholic  syndromes  in  well-marked  grades  of  imbecility 
would  appear  to  be  rare.  This  is  probably  in  part  due 
to  the  fact  that  imbeciles  do  not  stand  in  need  of  artificial 
excitants  of  a  subjective  bien  itre.  Chronic  alcoholism, 
as  well  as  criminal  tendency,  is  frequently  found  asso- 
ciated with  mild  degrees  of  imbecility,  but  not  by  any 
means  in  all  cases.  Even  imbeciles  enjoy  an  individual 
personality  peculiar  to  themselves,  and  though  presenting 
certain  features  in  common,  they  do  not  all  act  in  the 
same  way. 

(B)  PARANOIA 

In  the  writer's  experience  paranoiacs  with  systematized 
delusions  seldom  suffer  from  ordinary  psychoses.  In  badly 
managed  asylums  they  occasionally  develop  as  the  result 
of  injudicious  opposition  and  tactless  handling,  a  species 
of  maniacal  excitement,  of  a  resentful,  angry,  reckless 
type,  entirely  devoid  of  the  hilarity,  bonhomie  and 
divertibility  of  the  maniac,  and  lasting  a  few  weeks. 
Also  as  the  result  of  the  opposition  of  their  fellows  they 
may  suffer  from  attacks  of  sullen  depression,  free  however 
from  indecision  or  self-depreciation. 


1T2    ATYPICAL  AND  COMBINED  PSYCHOSES 

It  is  more  than  doubtful  if  these  syndromes  have  any 
relation  to  manic-depressive  insanity. 

Amentia  in  mature  paranoiacs  would  appear  to  be 
rare  :  the  same  is  true  of  alcoholic  syndromes.  Epileptic 
fits  are  however  not  so  uncommon.  Psychasthenia  is 
said  to  be  opposed  to  the  paranoiac's  temperament, 
and  in  fact  it  does  not  occur  in  well  marked  delusional 
cases  of  paranoia. 

It  is  an  attractive  and  not  untenable  hypothesis  that 
the  individual  cases  of  ordinary  psychoses  which  manifest 
a  tendency  to  systematized  delusions  are  in  reality  the 
result  of  a  combination  of  the  psychosis  with  a  paranoical 
temperament  (vide  Paranoia,  p.  61).  Examples  are, 
periodic  mania  with  paranoidal  delusions,  alcoholic 
paranoia,  systematized  delusions  in  G.P.I. ,  melancholia 
with  delusions  of  persecution  or  chronic  hypochondria, 
certain  systematized  types  of  dementia  paranoides. 
These  have  been  noticed  under  their  appropriate  headings. 
Some  epileptics  develop  more  or  less  systematized  delu- 
sions of  persecution,  more  prominent  during  their  equiva- 
lents, but  present  always.  It  is  not  unlikely  that  these 
are  also  possessors  of  the  paranoical  temperament. 
The  more  systematized  varieties  of  dementia  paranoides 
mentioned  above  manifest  in  their  early  stages  a  remark- 
able resemblance  to  paranoia.  The  patients  often  relate 
a  connected  scheme  of  imaginary  persecution  extending 
back  over  a  considerable  period  of  years,  unaccompanied 
by  apathy,  katatonia,  mannerisms  of  conduct  or  speech, 
exaggerated  or  intrinsically  impossible  statements,  and 
all  the  ordinary  signs  of  dementia  prsecox  (which  are  of 
later  development).  Another  type  of  the  same  condition 
resembles  the  religious  varieties  of  paranoia  very  closely. 
These  coherent  delusional  conditions  often  come  under 
the  notice  of  the  alienist  when  the  patient  is  between 
30  and  40  years  of  age,  relatively  early  for  paranoiacs 


COMBINED  AND  ATYPICAL  PSYCHOSES     173 

and  late  for  adolescent  dements.  Whether  the  paranoical 
temperament  is  regarded  as  playing  any  part  in  their 
aetiology  or  not,  the  clue  to  their  diagnosis  is  the  coin- 
cidence, however  rarely,  of  pseudo-hallucinations — not 
always  easy  to  elicit,  but  conclusive  when  found  with 
delusions  of  this  nature. 

The  paranoical  early  forms  of  G.P.I,  have  been  noticed 
and  they  are  probably  not  so  rare  as  they  would  appear 
to  be.  In  one  or  two  cases  the  writer  has  been  able  to 
elicit  by  inquiry  from  relatives,  etc.,  evidences  pointing 
to  a  paranoical  temperament  in  the  patient  years  before 
the  onset  of  the  G.P.I. 

The  paranoical  temperament  is  said  also  to  be  opposed 
to  the  hysterical,  and  yet  we  see  cases  of  paranoia  enjoying 
— in  states  of  emotional  exaltation — hallucinations, 
trances,  etc. — showing  that  they  are  capable  of  developing 
the  dissociations  of  hysteria,  just  as  normal  persons  are 
under  stress  of  circumstances.  In  passing,  it  may  be 
said  that  the  delusions  of  paranoiacs  are  probably  ana- 
logous to  the  dreams  of  hysteria,  i.e.,  disguised  wish 
fulfilments. 

Some  varieties  of  so-called  chronic  neurasthenia 
with  delusions  of  bodily  illness  are  probably  in  part  the 
result  of  a  paranoical  temperament,  the  delusion  not  par- 
taking of  the  nature  of  a  reaction  to  a  subconscious  fear, 
or  an  irrepressible  idea,  but  a  conviction  which  is  wel- 
comed by  the  temperament  of  the  patient — embraced  as. 
in  accordance  with  his  tendency  to  preconception — and 
not  resisted.  Signs  of  neurasthenia  may  co-exist,  and 
it  is  not  unlikely  that  the  temperament  has  been  lighted 
up  by  the  neurasthenia.  Probably  a  considerable 
number  of  the  motley  cases  labelled  hypochondria  are 
of  this  combined  nature.  Such  patients  do  not  manifest 
any  deep  depression,  impediment  of  will  or  self- deprecia- 
tion. 


174    ATYPICAL  AND  COMBINED  PSYCHOSES 

There  are  other  classes  of  hypochondriacs  who  would 
appear  to  be  combinations  of  melancholia  with  the 
paranoical  temperament.  They  are  depressed,  obstinate, 
and  exhibit  fixed  delusions  of  persecution  (possible  in 
type),  together  with  some  degree  of  self -depreciation, 
regarding  the  persecution  as  their  just  deserts.  Such 
types  usually  occur  after  middle  life  and  do  not  tend  to 
recover. 

(C)  CONSTITUTIONAL  IMMORALITY 

Considering  this  condition  merely  as  a  chronic  form 
of  excessive  misconduct,  without  any  implication  that 
it  is  a  special  inherent  form  of  anomaly,  it  may  be  studied 
in  its  relationship  to  forms  of  psychosis  (vide  p.   147). 

The  subject  is  par  excellence  the  province  of  the  prison 
doctor,  and  the  present  writer's  experience  of  it  has  been 
limited. 

Imbecility  would  appear  to  be  the  most  common  con- 
dition associated  with  continual  immorality,  and  chronic 
alcoholism  with  constant  actions  of  criminal  nature. 
Cases  of  dementia  prsecox  in  their  incubation  stage  are 
not  uncommonly  very  immoral,  more  rarely  criminal, 
and  probably  this  is  the  explanation  of  the  development 
of  this  disease  so  frequently  in  juvenile  prisoners.  These 
criminal  or  immoral  stages  of  adolescent  dementia,  with- 
out conspicuous  mental  symptoms,  are  said  to  be  pro- 
longed in  some  cases  over  a  period  of  years.  General 
paralytics  in  their  early  phases  sometimes  exhibit  a  flare- 
up  of  misconduct,  but  as  a  rule  there  is  not  much  difficulty 
in  the  diagnosis  ;   moreover  this  stage  is  short. 

The  association  of  insistent  sinning  with  epilepsy  is 
probably  much  less  general  than  is  supposed.  In  fact  it 
is  commonly  found — at  least  it  has  been  the  present 
writer's    experience — that    even    demented     epileptics 


COMBINED  AISTD  ATYPICAL  PSYCHOSES     175 

retain  a  most  marked  sense  of  right  and  wrong  which  they 
endeavour  to  live  up  to.  Epileptics  are  of  course  prone 
to  outbursts  of  rage,  but  it  is  remarkable  how  well  they 
control  themselves  if  properly  handled.  Unconscious 
or  semi-conscious  crimes  in  epileptics,  the  result  of 
"  equivalents,"  not  uncommonly  occur.  But,  and  this 
would  appear  to  be  an  important  point- — when  an  epi- 
leptic or  a  person  of  epileptic  temperament  is  also  a 
chronic  alcoholic,  not  only  is  he  prone  to  more  frequent 
unconscious  crimes,  but  being  brutalized  by  his  alcohol- 
ism, and  his  volition  impaired,  he  may  commit  a  series 
of  crimes  that  are  conscious  and  even  deliberate.  The 
following  is  an  interesting  mixed  case  : 

T.C.,  aged  35,  had  started  life  in  some  sort  of  industrial 
school  because  he  was  destitute.  After  leaving  that 
institution  he  embarked  upon  a  career  of  petty  crime 
terminating  in  a  term  of  penal  servitude  for  burglary. 
While  in  prison  he  mutilated  himself  and  was  placed 
under  mental  observation.  As  he  was  not  sent  to  an 
asylum,  but  continued  to  serve  his  sentence,  the  inference 
is  that  he  was  not  considered  insane.  Subsequently  he 
joined  the  Army,  and  was  in  the  habit  of  wearing  the 
South  African  ribbon,  to  which  he  had  no  right.  In  the 
service  he  continually  offended  and  malingered,  and 
when  punished  became  excited,  truculent,  and  full  of 
ideas  of  unjust  treatment.  He  eventually  deserted ; 
was  arrested  and  sentenced  to  twenty-eight  days'  deten- 
tion. During  his  imprisonment  he  stabbed  himself  in 
the  chest  with  a  jack-knife,  and  was  therefore  sent  to  me 
for  observation. 

He  was  found  to  be  a  blustering  threatening  blackguard, 
almost  entirely  devoid  of  altruism,  and  full  of  ideas  of 
grievances  against  his  officers.  He  was  absolutely  re- 
solved to  commit  suicide  if  sent  back  to  serve  his  sentence. 
He   was   cunning   and  boastful,   suspicious,   sullen  and 


176    ATYPICAL  AND  COMBINED  PSYCHOSES 

resentful.  But  in  addition  to  all  this  he  manifested 
certain  features  which  lent  considerable  clinical  interest 
to  his  case.  There  were  present  some  degree  of  childish 
weak-mindedness  with  a  congenital  defect  in  articulation ; 
liability  to  violent  outbursts  of  temper  with  violence, 
periodic  depression  of  spirits,  and  anomalous  "  fits,"  the 
nature  of  which  I  am  doubtful  about  to  this  day. 

After  discharge  from  the  army  he  falsified  his  discharge 
papers,  in  a  silly  childish  fashion,  represented  that  he 
had  been  invalided  from  the  Front  as  the  result  of  the 
wound  (self-inflicted  in  fact)  in  his  chest,  by  a  German 
bayonet,  and  on  this  plea  endeavoured  to  obtain  money 
from  charitable  organizations.  When  the  fraud  was 
at  once  discovered,  he  mutilated  himself  again.  Finally 
there  was  an  independent  history  that  he  had  been  picked 
up  in  the  street  on  two  or  three  occasions  and  taken  to 
hospital.  Unfortunately  no  details  of  these  incidents 
could  be  obtained.  He  was  not  a  chronic  alcoholic.  The 
reading  of  the  case  formed  at  the  time  was  that  it  was  one 
of  high  grade  imbecility  combined  with  epilepsy,  the 
incessant  criminality  being  the  result  of  both  and  also  of 
his  early  environment. 

2.  COMBINATIONS  OF  ANOMALIES  WITH 

ANOMALIES 

The  severest  forms  of  psychopathic  inheritance  (the 
so-called  degenerative  types)  are  regarded  as  being 
expressed  by  the  paranoical  temperament  and  by  im- 
becility, and  it  is  not  unnatural  that  such  conditions 
should  be  occasionally  found  combined  in  one  individual. 
Actual  paranoia  with  systematized  delusions  however, 
precludes  a  co-existent  imbecility  of  any  marked  degree, 
as  considerable  intelligence  is  necessary  for  the  pro- 
duction of  this  systematization.     For  the  same  reason 


COMBINED  AND  ATYPICAL  PSYCHOSES    177 

well-marked  imbeciles  of  paranoical  temperament  do  not 
develop  properly  systematized  delusions. 

With  regard  to  constitutional  immorality  (in  the 
sense  of  incessant  misconduct)  in  persons  of  paranoical 
temperament  merely,  it  would  appear  to  be  rare.  Pure 
cases  of  paranoia  rarely  embark  upon  a  career  of  crime 
or  immorality  even  when  markedly  delusional. 

On  the  other  hand,  imbeciles  are  well  known  to  be 
prone  to  wickedness,  and  this  tendency  is  naturally  more 
powerful  when  accompanied  by  paranoidal  delusions, 
which  act  as  additional  motives  for  and  causes  of  mis- 
conduct, e.g.,  in  cases  with  persecutory,  querulent,  erotic 
and  exalted  ideas.  In  the  case  of  Mattoids  (examples  of 
the  paranoical  temperament  with  abortive  altruistic 
delusions),  although  these  persons  are  always  slightly 
imbecile,  they  are  not  prone  to  crimes,  etc.,  owing  to  the 
nature  of  their  erroneous  ideas.  The  slight  imbecility 
present  in  them  has  not  improbably  prevented  the  com- 
plete development  of  systematized  delusions  characteristic 
of  more  fully  developed  types  of  paranoia. 

Although  all  imbeciles  are  potentially  immoral  it  must 
not  be  imagined  that  they  invariably  became  so  in  fact. 
Even  imbeciles  have  individual  characters  peculiar  to 
their  own  ego,  although  they  all  manifest  certain  traits  in 
common ;  and  again,  upbringing,  environment,  and 
opportunity  are  potent  factors  in  determining  the  moral 
or  immoral  nature  of  their  conduct.  They  are  not  much 
restrained  from  misconduct  by  principles  or  altruism,  but 
by  absence  of  inclination,  or  lack  of  the  opportunity, 
which  they  are  too  fatuous  to  create  for  themselves. 

Nevertheless  the  vast  majority  of  chronic  criminals 
show  definite  signs  of  imbecility — that  is,  if  they  show 
any  signs  of  abnormality  at  all. 


b.m,d,  12 


178    ATYPICAL  AND  COMBINED  PSYCHOSES 

3.  COMBINATIONS  OF  PSYCHOSES  AND 
NEUROSES  WITH  EACH  OTHER 

(A)  DEMENTIA  PRECOX 

The  following  are  common  conditions  which  may  be 
found  associated  with  dementia  prsecox  : — 

1.  Neurasthenia   (of   both  types)   and  psychasthenia. 

2.  Amential  confusion. 

3.  Hysteria. 

4.  Epileptic  fits. 

5.  Alcoholic  mental  symptoms. 

1.   Association   with   Neurasthenia   and  Psychasthenia 

More  or  less  acute  neurasthenic  and  psychasthenic 
symptoms  often  immediately  precede  and  usher  in  de- 
mentia prsecox.  Given  a  recognized  case  of  the  latter,  it 
is  of  course  a  work  of  supererogation  to  discover  neuras- 
thenic symptoms,  but  in  cases  of  neurasthenia  it  is  of 
exceeding  importance  to  recognize  signs  of  a  developing 
adolescent  dementia.  There  is  reason  for  believing  that 
such  cases  can,  by  suitable  measures,  be  checked  and 
possibly  aborted  at  this  stage. 

In  the  observation  of  such  cases  attention  should  be 
paid  to  the  following  points  : — 

(a)  Ideation 

The  intrusion  into  the  patient's  mind  of  peculiar  and 
often  absurd  ideas,  which,  instead  of  creating  an  unplea- 
sant emotional  tone  of  conflict  and  exhibiting  the  charac- 
teristic feature  of  irrepressibility  (vide  p.  124),  merely 
puzzle  the  patient  about  himself  without  being  recognized 
as  pathological  intruders,  strongly  suggests  the  co- 
existence of  dementia  prsecox. 

A  further  development  of  these  ideas  into   audible 


COMBINED  AND  ATYPICAL  PSYCHOSES     179 

thought  (pseudo- hallucinations)  is  an  almost  certain 
indication  of  the  same  affection  :  at  any  rate  a  conclusive 
proof  that  the  patient  is  not  merely  suffering  from  neur- 
asthenia. Pure  cases  of  psycho-neurasthenia  often  ex- 
hibit hypochondriacal  fancies  due  to  and  partaking  of 
the  nature  of  fears  (phobias)  and  due  in  part  to  ccenes- 
thetic  disturbances.  These  are  merely  doubts  resulting 
from  anxiety.  Fixed  (not  necessarily  permanent)  belief 
in  the  existence  of  special  bodily  diseases,  in  spite  of 
assurance  to  the  contrary  by  those  qualified  to  express 
an  opinion,  indicates  something  more  than  neurasthenia, 
— probably  in  adolescents,  dementia  prsecox. 

It  is  hardly  necessary  to  say  that  simple  neurasthenia 
never  results  in  obvious  delusions   (or   hallucinations). 

(b)  Emotions 

Though  neurasthenics  of  long  standing  may  become 
resigned  in  a  dull  sort  of  way,  uncomplicated  cases  are 
never  apathetic.  Definite  indifference  in  early  combined 
cases  may  not,  however,  be  very  obvious.  The  patient 
may  appear  unstrung  and  agitated,  but  occasionally  one 
is  able  to  detect  the  first  glimmerings  of  the  causeless 
smile  of  dementia  praecox.  These  early  foreshado wings 
of  motiveless  acts  do  not  as  yet  take  a  typical  form,  but 
are  manifested  by  frequent  and  causeless  smiling  (smiling 
that  is  not  forced,  half-hearted,  pathetic  or  hysterical), 
in  agitated  restless  types,  during  conversation.  It  is  a 
thorough  smile,  but  one  not  excited  by  external  stimuli 
to  mirth,  nor  due  to  amiability.  Normal  individuals 
may  have  an  automatic  trick  of  frequent  and  thorough 
smiling  ;    agitated  neurasthenics  certainly  have  not. 

With  regard  to  the  depression  of  neurasthenics,  it  may 
be  stated  that  lack  of  autocriticism,  the  presence  of  ex- 
aggerated display  or  insincerity,  should  raise  a  Strong 
suspicion  of  dementia  prsecox. 


180    ATYPICAL  AND   COMBINED  PSYCHOSES 

In  some  cases  of  neurasthenia  there  is  at  times  a  rapid 
fluctuation  of  mood  in  which  smiles  alternate  with  tears 
a  dozen  times  during  a  few  minutes'  conversation.  If 
these  changes  are  spontaneous  and  sincere  and  according 
to  the  conversation  they  are  probably  hysterical ;  if 
they  are  automatic  and  of  apparently  internal  origin,  they 
should  be  carefully  weighed. 

(c)  Conduct 

When  it  is  borne  in  mind  that  recent  neurasthenia 
tends  to  make  its  subject  timid,  modest,  and  kindly, 
sensitive,  introspective,  self-distrustful,  and  conscientious, 
it  will  be  readily  recognized  that  any  course  of  action 
directly  opposed  to  such  characteristics  should  give  rise 
to  grave  suspicions.  Neurasthenics  do  not  act  even  in 
direct  opposition  to  their  former  characters  when  in 
health,  in  virtue  of  neurasthenia  alone.  They  have  less 
tendency  than  normal  persons  to  blatancy,  vice,  boasting, 
immodesty,  cruelty,  clownism,  and  absurd  and  purposeless 
perversity  of  conduct.  Seclusiveness  may  occur  in  cases 
of  simple  neurasthenia  and  also  in  dementia  prsecox. 
In  the  former  case,  however,  it  is  a  concomitant  of  fear 
of  society,  shyness,  or  some  special  phobia  :  in  the  latter 
it  is  either  motiveless  or  due  to  a  direct  and  excessive 
desire  for  solitude.  Marked  seclusiveness  in  neurasthenic 
adolescents  (not  pubescents)  becoming  more  accentuated 
with  the  decline  of  acute  neurasthenic  symptoms  may  be 
due  to  masturbation,  or  the  onset  of  dementia  prsecox,  or 
to  psycho-analysis  (!). 

A  moderate  degree  of  seclusiveness  in  boys  and  girls 
at  the  period  of  puberty  may  mean  nothing  at  all,  or  it 
may  be  the  result  of  shame  resulting  from  masturbation, 
or  an  indication  of  a  psychopathic  temperament. 

Obsessive  impulses  to  action  which  are  yielded  to  have 
been  noticed  on  page  126. 


COMBINED  AND  ATYPICAL  PSYCHOSES     181 

It  should  not  be  necessary  to  state  that  katatonia  and 
catalepsy  do  not  occur  in  uncomplicated  neurasthenia. 

(d)  Pedantry  est  Speech 

Neurasthenics  who  give  pseudo-scientific,  "  highflown  " 
or  absurd  explanations  of  their  feelings  should  be  regarded 
with  suspicion,  but  in  judging  symptoms  of  this  sort, 
especially,  one  must  take  into  account  the  individual.  If 
a  young  and  characteristic  farm-labourer  with  recent 
neurasthenia  informed  me  that  he  thought  he  must  be 
suffering  from  "  an  insufficient  flow  of  blood  to  the  vital 
organs,"  I  should  watch  him  narrowly  for  signs  of  demen- 
tia prgecox.  If  a  medical  student  made  such  a  remark, 
I  should  ask  him  what  the  deuce  he  meant ! 

It  may  be  said  that  a  sudden  development  of  pedantry 
in  a  neurasthenic  savours  Very  strongly  of  dementia 
precox. 

(e)  Physical  Signs 

When  neurasthenia  is  at  all  acute,  whether  dementia 
praecox  be  developing  or  not,  physical  signs  of  the  former 
are  present. 

But  if  a  young  man  complains  (usually  as  the  result  of 
misguided  leading  questions)  of  feeling  agitated,  appre- 
hensive, "  nervy,"  run  down,  and  depressed,  at  the  time 
of  examination,  and  yet  manifests  no  dilatation  of  the 
pupils,  tremors,  miserable  appearance,  tachycardia,  low 
tension  pulse,  but  on  the  contrary  looks  perfectly  well, 
cheerful  and  calm  he  is  either  a  case  of  some  psychosis 
(probably  dementia  prsecox)  or  a  liar. 

Finally,  it  may  be  said  that  neurasthenia  arising  for  the 
first  time  in  adolescents  without  any  particular  or  suffi- 
cient external  cause,  should  at  least  engender  in  the  mind 
of  the  medical  man  a  determination  to  watch  the  case 
with  great  care. 


182    ATYPICAL  AND  COMBINED  PSYCHOSES 

In  combined  cases,  as  the  disease  develops  so  the 
neurosis  disappears.  Advanced  cases  of  dementia  prsecox 
being  emotionless  are  immune  to  neurasthenia. 

One  or  two  other  points  are  of  some  importance. 

Reticence  in  neurasthenics  is  uncommon.  Once  their 
confidence  has  been  obtained — no  difficult  matter  for  a 
sympathetic  physician — they  will  unburden  themselves 
with  eagerness,  and  are  better  therefor.  A  case  of 
neurasthenia  in  an  adolescent  with  whom  it  is  difficult 
to  get  en  rapport  and  who  manifests  marked  reserve  in 
his  conversation,  should  be  narrowly  watched  for  signs 
of  dementia  prsecox. 

Suggestibility  is  an  allied  feature  to  communicativeness. 
Simple  neurasthenics  are  suggestible.  You  cannot  re- 
move the  emotional  symptoms  they  experience  as  the 
result  of  the  disturbance  of  their  ccenesthesis,  but  you 
can  explain  their  source  and  be  believed,  you  can  ame- 
liorate their  intensity  by  kind  therapeutic  conversation. 
Lack  of  this  suggestibility  is  presumptive  evidence  of  a 
psychosis  of  some  sort :  its  exact  nature  will  eventually, 
or  perhaps  at  once,  be  apparent  from  other  signs. 

Neurasthenics  in  the  acute  stages  puzzle  about  their 
feelings  (unless  they  have  had  them  before  and  are 
familiar  with  them),  but  their  perplexity  is  accompanied 
by  anxiety,  and  somatic  apprehension.  Self-perplexity, 
apart  from  these  features,  smacks  of  dementia  prsecox. 

2.  Association  of  Dementia  Prsecox  with  Confusional 

Episodes 

The  recognition  of  confusional  intoxication  conditions 
in  known  cases  of  dementia  prsecox  is  of  academic  interest 
only,  but  the  reverse  is  the  case  where  an  attack  of  con- 
fusion presents  itself  for  diagnosis  in  an  adolescent.  The 
common  association  of  the  two  syndromes  is  at  the  onset, 


COMBINED  AND  ATYPICAL  PSYCHOSES     183 

or  apparent  onset,  of  the  dementia  prsecox,  and  the  dia- 
gnosis of  the  latter  rests  upon  the  observation  of  its 
special  features. 

In  the  excited  varieties  of  confusion  in  these  cases  the 
amential  syndrome  is  represented  by  disorientation, 
varying  degrees  of  inaccessibility,  restlessness,  appre- 
hension, etc.,  continual  hallucinations,  and  in  severe 
cases,  imperception. 

The  indication  of  adolescent  demential  symptoms  to  be 
looked  for  are  the  usual  characters  of  that  disease.  Signs 
of  basic  apathy  can  sometimes  be  made  out,  e.g.,  conduct 
out  of  proportion  to  the  intensity  of  the  emotional  state, 
periods  of  apathy,  theatrical  display,  obvious  insincerity, 
the  smile  of  dementia  prsecox.  Flight  of  ideas  is  not 
usually  very  marked  and  hence  the  speech  is  not  so  much 
disintegrated  as  meaningless  and  absurd  in  the  mixed 
types  ;  it  may  be  infrequent,  and  occasionally,  entirely 
absent.  Continual  verbigeration  of  unintelligible  phrases 
suggests  dementia  prsecox.  With  regard  to  conduct, 
marked  degradation  and  sexual  colouring  apart  from 
very  deep  clouding  of  consciousness  is  also  in  favour  of 
that  disease.  Deliberate  and  clever  malice  at  once  puts 
pure  amentia  out  of  court.  Negativism  does  not  often 
occur  apart  from  dementia  prsecox,  but  katatonia  in 
some  form  would  appear  to  do  so  in  simple  amentia  in 
adolescents.  I  have  not  seen  many  such  cases,  and 
they  have  never  been  followed  up  after  their  apparent 
recovery. 

It  is  not  unknown  for  cases  of  actual  dementia  prsecox 
to  subside  or  remain  latent  for  prolonged  periods  after  an 
acute  onset.  One  of  the  writer's  doubtful  types  was  a 
severe  cardiac  case  with  albuminuria  and  dropsy.  Con- 
fusion with  disorientation  and  almost  complete  inaccessi- 
bility existed  with  verbigeration,  negativism,  occasional 
mutacismus,  dirty  habits,  and  a  mood  of  no  very  pro^ 


184    ATYPICAL  AND  COMBINED  PSYCHOSES 

nounced  colouring.  There  was  of  course  cachexia.  The 
onset  had  been  acute,  and  the  recovery  was  apparently 
complete  and  followed  by  amnesia  for  the  attack.  A 
previous  attack  had  occurred  a  few  weeks  before  with 
clouding  of  consciousness  and  apprehension,  but  without 
any  signs  of  katatonia.  Unfortunately  a  few  months 
after  recovering  from  the  second  attack,  the  man  died 
from  the  cardiac  condition.  In  cases  of  this  sort  with 
considerable  clouding  of  consciousness,  absence  of  emo- 
tional tone  and  reaction  may  be  merely  amential  symp- 
toms ;  conspicuous  and  sincere  emotional  states  however 
exclude  dementia  prsecox. 

In  the  milder  attacks  of  confusion  at  the  onset  of  de- 
mentia prsecox,  the  characteristic  features  of  the  latter 
are  sometimes  difficult  to  make  out  and  the  cases  very 
obscure.  They  are  more  like  paranoidal  amentia  than 
any  other  single  syndrome.  There  is  confusion,  dis- 
orientation, but  complete  accessibility  and  good  simple 
perception.  Memory  for  times  especially  is  defective, 
and  there  is  some  impediment  of  thought.  There  is  in 
some  cases  a  sense  of  illness  and  not  infrequently  personal 
perplexity.  Delusions  mainly  of  persecution  are  present 
and  conspicuous  hallucinations,  principally  auditory. 
With  all  these  features  the  mood  is  on  the  whole  apathetic, 
and  the  emotional  reaction  markedly  deficient.  This 
basic  apathy  with  complete  accessibility  is  the  key  to  the 
picture. 

Stuporose  cases  in  adolescents  with  clouding  of  con- 
sciousness may  be  either  simple  amentia  attonita  or 
dementia  prsecox  combined  with  it.  Complete  dumbness 
and  immobility  may  exist  in  both,  together  with  inac- 
cessibility. The  features  of  dementia  prsecox  are  practic- 
ally impossible  to  demonstrate  in  such  cases.  Symptoms 
to  be  carefully  looked  for  are  minor  indications  of  kata- 
tonia such  as  strained  or  peculiar  attitudes,  negativism, 


COMBINED  AND  ATYPICAL  PSYCHOSES     185 

fiexibilitas  cerea,  and  causeless  smiling.  Another  variety 
of  confusional  episode  at  the  onset  of  dementia  prsecox 
is  a  sort  of  half-way  house  between  the  stuporose  and 
excited  types.  It  does  not  differ  materially  from  the 
mild  type  described  above.  The  patient  is  restless.  He 
continually  wanders  about ;  never  speaks  spontaneously, 
and  only  replies  in  a  word  or  irrelevantly  when  questioned. 
Hallucinations  are  less  prominent  than  in  the  class  pre- 
viously described  ;  delusions  appear  to  be  absent,  but 
confusion  and  disorientation  are  present.  Purposeless 
acts  and  other  katatonic  signs  are  much  more  obvious. 
The  self-perplexed  condition  and  the  smile  are  usually  in 
evidence.  The  mood  is  often  superficially  depressed  and 
really  indifferent.  The  main  difference  between  these 
two  mild  types  is  that  the  second  is  more  stuporose  and 
more  katatonic,  and  hence  much  easier  to  diagnose,  than 
the  first.  One  of  the  most  important  points  in  the  re- 
cognition of  dementia  prsecox  in  cases  of  confusion  with 
or  without  katatonia  is  the  previous  history  of  the  patient. 
If  there  is  reliable  evidence  that  his  previous  and  life- 
long temperament  was  one  of  the  reserved,  reticent, 
solitary,  studious  but  obstinate  types,  the  chances  are  a 
hundred  to  one  that  dementia  prsecox  is  present. 

Attacks  of  confusion  in  established  cases  of  dementia 
prsecox  are  not  common.  In  asylums  they  usually  mean 
auto-intoxication  from  constipation.  They  are  naturally 
easy  to  distinguish  from  pure  amentia  as  all  their  cardinal 
signs  are  present. 

3.  Hysteria  and  Dementia  Prsecox 

Persons  of  hysterical  temperament  seldom  develop 
dementia  prsecox.  The  main  features  of  the  latter,  e.  g., 
apathy,  non-suggestibility,  absent  or  feeble  emotional 
re-action,    are    directly   opposed    to    the    characters    of 


186    ATYPICAL  AND  COMBINED  PSYCHOSES 

hysterics.  Nevertheless  one  occasionally  sees  hysterical 
episodes  in  early  cases  of  dementia  praecox,  especially  the 
hebephrenic  types. 

The  frequency  of  the  association  of  hysteria  and  de- 
mentia praecox,  however,  is  probably  very  much  exag- 
gerated, owing  to  the  false  identification  of  different 
symptoms,  e.  g.,  perversity,  with  negativism  ;  hysterical 
weeping  and  laughing  (in  which  appropriate  emotions 
are  present  though  transitory,  and  uncontrollable),  with 
automatic  emotional  outbursts  ;  transitory  aphonia, 
with  mutacismus ;  passionate  but  ideal  eroticism, 
with  blatant  shameless  sexuality  (not  merely  a 
difference  of  degree,  but  of  character ;  the  hysteric 
is  erotic  from  great  exaltation,  the  stress  of  passion 
breaking  through  a  natural  modesty ;  the  adolescent 
dement  is  erotic  from  absence  of  modesty,  and  moral 
cynicism).  With  regard  to  "  attitudinizing  "  in  hysteria 
and  dementia  praecox,  the  distinctions  are  again  funda- 
mental. In  the  former  case  the  attitudes,  etc.,  adopted 
are  the  result  of  emotional  exaltation  and  they  express 
very  vividly  the  passion  they  represent.  In  dementia 
praecox  they  are  motiveless,  that  is  to  say,  not  the  result 
of  emotions  but  of  organic  stimuli.  Hysterical  cases 
very  commonly  act  in  a  most  theatrical  fashion  ;  their 
demeanour  may  change  with  great  rapidity  and  without 
external  cause  ;  but  because  they  experience  the  emotions 
their  conduct  displays,  they  act  very  well.  Cases  of 
dementia  praecox  also  occasionally  act  in  a  superficially 
similar  fashion,  but  their  performance  is  so  execrable  that 
it  constitutes  a  burlesque — obviously  insincere  and  often 
clownish — because  they  do  not  feel  the  emotions  they 
profess  to  portray.  Of  course,  much  of  the  attitudiniz- 
ing of  hysteria  is  subconcious,  the  patients  being  in  a 
state  of  dissociated  consciousness  easily  distinguished 
from  katatonia. 


COMBINED  AND  ATYPICAL  PSYCHOSES    187 

It  is  by  these  sorts  of  distinctions  that  dementia  prsecox 
may  be  recognized  where  it  is  associated  with  hysterical 
excitement  at  its  onset.  The  obvious  characteristic 
features  of  the  disease,  of  course,  would  not  be 
missed. 

Nevertheless  certain  mixed  hysterical  and  confusional 
cases  are  seen  in  which  strong  doubts  about  the  co-exist- 
ence of  dementia  prsecox  are  only  dissipated  by  the  course. 
For  example,  when  a  case  of  traumatic  "  neurasthenia  " 
(i.  e.,  hysteria,  though  naturally  true  neurasthenic  symp- 
toms may  be  present)  suddenly  becomes  perverse,  an- 
tagonistic, and  though  enjoying  perfect  perception  makes 
ridiculous,  but  not  meaningless,  statements  about  persons 
and  things,  suffers  from  hallucinations,  and  becomes  dirty 
in  habits,  one  begins  to  entertain  doubts  concerning  the 
nature  of  the  malady  present.  Attacks  of  this  sort  are 
transitory  if  dementia  prsecox  be  not  present,  and  com- 
plete recovery  occurs  in  a  few  days.  Such  cases  often 
show  a  certain  degree  of  apathy  during  the  attack,  and 
I  do  not  know  any  reliable  means,  except  the  course,  of 
excluding  a  possible  early  adolescent  dementia.  Here 
again,  however,  the  patient's  previous  temperament  is  of 
value.  If  it  was  of  hysterical  type  the  case  is  probably 
not  dementia  prsecox  ;  if  it  was  of  the  dementia  prsecox 
type  (vide  p.  102)  that  disease  is  probably  present. 

4.  Dementia  Prsecox  and  Epilepsy 

That  adolescent  dements  do  occasionally  suffer  from 
true  epileptic  fits  at  very  infrequent  intervals  is  well 
known  to  asylum  doctors.  Patients  of  this  sort  are  in- 
distinguishable from  ordinary  cases  of  dementia  prsecox. 
The  association  is  probably  accidental.  The  present 
writer  has  never  seen  a  case  of  dementia  prsecox  with 
chronic  epilepsy. 


188     ATYPICAL  AND  COMBINED  PSYCHOSES 


5.  Alcoholic  Syndromes  and  Dementia  Praecox 

As  all  the  alcoholic  psychoses  are  the  result  of  chronic 
toping,  and  dementia  praecox  is  mainly  a  disease  of  adoles- 
cence, combinations  of  these  two  conditions  should  be 
rare.  This  is  found  to  be  the  case.  A  small  number  of 
the  later  developing  types  of  dementia  praecox  manifest 
symptoms  of  chronic  alcoholism  ;  but  these  are  also 
rare,  which  is  perhaps  rather  remarkable  in  view  of  the 
assertion  that  the  subjects  of  dementia  praecox  are  "  de- 
generates." It  is  not  unlikely  that  there  is  another  reason 
than  age  to  account  for  this  rarity,  a  reason  associated 
with  an  inherent  temperament  in  those  especially  liable 
to  dementia  praecox.  Perhaps  for  persons  of  this  tempera- 
ment alcohol  has  no  attractions.  Be  this  as  it  may,  there 
is,  I  think,  no  doubt  that  the  common  type  of  adolescent 
who  subsequently  develops  dementia  praecox  is  the  quiet, 
studious,  self-contained  and  rather  seclusive  youth — the 
stamp  of  young  person  who  is  addicted  to  masturbation 
and  smoking  rather  than  women  and  wine  ;  another 
possible  explanation  is  that  alcohol  in  some  way  prevents 
the  development  of  the  metabolic  disorder  which  is  re- 
garded as  partly  responsible  for  dementia  praecox — a 
chemical  theory.  This  appears  much  less  likely  on 
several  grounds.  Nevertheless  neurasthenia,  also  re- 
garded as  in  part  due  to  auto-intoxication,  is'  in  many 
cases  definitely  benefited  by  moderate  indulgence  in 
alcohol. 

In  mixed  alcoholic  and  adolescent  demential  psychoses 
the  important  point  is  of  course  to  demonstrate  dementia 
praecox,  in  some  cases  no  easy  task.  One  should,  of 
course,  be  on  the  alert  for  the  katatonic  syndrome,  signs 
of  basic  apathy,  purposeless  acts,  meaningless  speech, 
etc. 


COMBINED  AND  ATYPICAL  PSYCHOSES     189 

(B)  MANIA  ASSOCIATED  WITH  OTHER  PSYCHOSES 

Mania  would  appear  to  be  found  in  combination  chiefly 
with  the  following  common  syndromes  : — 

1.  Melancholia. 

2.  Confusional  attacks  (i.  e.,  amential). 

3.  The  psychoses  of  chronic  alcoholism. 

4.  Hysteria. 

1.  Two  combinations  of  mania  with  melancholia  are 
described,  viz.  maniacal  stupor  and  melancholic  mama. 

The  former  has  been  described  on  page  95.  The  latter 
is  said  to  present  a  picture  of  restless  noisy  melancholia, 
with  press  of  occupation,  rapid  mental  action,  hypersensi- 
tiveness  to  external  impressions,  occasional  remissions 
in  the  unhappiness,  and  divertibility,  to  varying  extents. 


2.  Mania  with  Intoxication  Symptoms 

Confusional  symptoms  in  severe  acute  mania  are  not 
uncommon  as  the  attack  proceeds,  and  when  developed 
the  case  presents  a  picture  sometimes  indistinguishable 
from  amentia  agitata.  The  distinguishing  features  of 
the  combined  psychosis,  when  manifest,  are  as  follows  : — 

Apprehension  is  transitory  and  may  be  absent,  the 
mood  for  the  most  part  being  wildly  exalted.  Perception 
of  the  nature  of  objects  is  preserved.  Hallucinations  are 
not  so  all-absorbing  as  in  severe  amentia,  and  inaccessi- 
bility is  much  less  pronounced. 

With  these  divergences  from  amentia  agitata,  there 
is  a  degree  of  motor  and  emotional  excitement  equal  to 
that  found  in  that  affection.  In  cases  where  the  history 
is  known  a  gradual  onset  of  hypomaniacal  type  naturally 
excludes  simple  amentia. 


190    ATYPICAL  AND  COMBINED  PSYCHOSES 

3.  Chronic  Alcoholism 

Certain  cases  are  met  with  in  which  symptoms  of  mania 
are  accompanied  by  alcoholic  features  and  preceded  by  a 
history  of  chronic  alcoholism.  It  is  doubtful  if  such  are 
to  be  regarded  as  purely  alcoholic  syndromes  or  combined 
psychoses  in  which  the  alcoholism  has  lighted  up  an  attack 
of  mania. 

The  so-called  alcoholic  mania  (acute  hallucinatory 
delusions)  is  usually  not  in  the  least  like  mania,  but  cases 
such  as  the  following  are  not  very  uncommon  : — 

The  patient  is  moderately  excited  and  restless,  mani- 
festing press  of  occupation,  and,  when  started  off,  garrul- 
ity with  perfectly  intelligible  though  incoherent  speech, 
indicating  considerable  flight  of  ideas.  The  mood  is  one 
of  exaltation  and  amicable  hearty  cheerfulness,  quite  free 
from  apprehension.  He  expresses  transitory  delusions  of 
persecution  such  as  injury,  mesmerism,  etc.,  without 
showing  any  appropriate  emotional  tone.  Illusions  and 
hallucinations  of  hearing  are  present,  with  keen  passive 
attention,  complete  accessibility,  quick  perception.  Dis- 
orientation in  time  and  space  is  present. 

He  is  markedly  divertible,  and  has  a  certain  air  of 
futility  and  childishness.  Finally,  some  evidence  of 
pseudo-reminiscence  is  not  uncommon,  together  with 
physical  signs  of  chronic  alcoholism.  Complete  recovery 
ensues. 

Cases  of  this  sort  are  to  be  distinguished  from  maniacs 
with  auto-intoxication  (amential)  symptoms,  from  general 
paralysis,  and  from  chronic  hallucinatory  delusions 
(alcoholic)  of  hilarious  type. 

In  the  exhaustion  pictures  of  mania,  hallucinations 
are  less  prominent,  in  view  of  the  excitement,  both 
emotional  and  intellectual  being  more  marked,  and  in- 
accessibility more  pronounced,  than  is  the  case  in  these 


COMBINED  AND  ATYPICAL  PSYCHOSES     191 

alcoholic  maniacs.  In  the  latter  the  power  of  active 
attention  is  better  preserved,  and  confusion  is  present 
from  the  onset,  which  is  acute.  Confusional  symptoms 
in  mania  supervene  gradually  as  the  case  becomes  worse, 
and  eventually  produce  a  more  acute  picture  of  excite- 
ment with  cachexia.  To  distinguish  cases  such  as  that 
described  above  from  excited  confusional  attacks  in 
early  G.P.I,  is  by  no  means  easy.  Features  of  this  latter 
to  be  looked  for  are  expansive  delusions  and  physical 
signs.  It  should  also  be  borne  in  mind  that  hallucinations 
of  hearing  are  rare  in  general  paralysis  apart  from  para- 
lytic delirium,  and  that  perception  and  passive  attention 
are  more  active  in  the  alcoholic  state.  That  is  to 
say,  the  alcoholic  is  generally  more  alert  and  his  mental 
action  is  quicker  than  in  the  case  of  a  paralytic  of  pro- 
portionate excitement  and  clouding  of  consciousness. 
Cases  of  paralytic  delirium  are  much  more  deeply  clouded 
and  much  less  accessible. 

With  regard  to  chronic  alcoholic  hallucinatory  delu- 
sions ; — in  this  condition  disorientation,  confusion  about 
persons  and  environment  and  time,  press  of  occupation, 
flight  of  ideas,  and  hyperacute  passive  attention,  are 
absent.  In  short,  neither  the  confusional  nor  all  the 
maniacal  symptoms  are  present. 

Some  further  associations  of  alcoholism  with  manic- 
depressive  syndromes  will  be  noted  under  the  title  of 
complications  of  melancholia  (p.  195). 

4.  Associations  of  Mania  with  Hysteria 

Persons  with  a  well-marked  hysterical  temperament 
appear  to  be  rather  more  liable  to  attacks  of  mania  than 
are  normal  persons,  but  the  attacks  are  short  and  the 
prognosis  is  good. 

In  women,  hysterical  emotional  symptoms  are  common 


192     ATYPICAL  AND  COMBINED  PSYCHOSES 

at  the  onset  of  mania,  but  the  former  should  not  be  mis- 
taken for  the  latter.  Flight  of  ideas,  divertibility,  and 
press  of  occupation  are  not  seen  in  hysterical  excitement, 
moreover  the  extreme  loss  of  control  and  emotional 
exaltation  of  the  latter  would  only  be  found  in  severe 
cases  of  mania  with  all  its  cardinal  symptoms  well  marked. 
Finally,  pure  hysterical  paroxysms  only  last  a  few  hours. 

(C)  MELANCHOLIA  AND  ASSOCIATED  PSYCHOSES  AND 
NEUROSES 

Melancholia  is  not  uncommonly  found  associated  with — 

1.  Neurasthenia  (including  both  types)  and  psych- 
asthenia. 

2.  Mania. 

3.  Amential  confusional  episodes. 

4.  Chronic  alcoholism. 

5.  Hysteria. 

1.  Melancholia  with  Psycho- Neurasthenia 

Some  notes  on  this  subject  in  reference  to  differential 
diagnosis  will  be  found  on  page   120. 

Psycho-neurasthenia  is  not  common  in  association 
with  mania,  but  it  is  more  commonly  combined  with 
melancholia  than  might  appear  to  be  the  case  at  first 
sight,  probably  because  in  private  practice  cases  of  melan- 
cholia developing  in  the  train  of  the  other  condition  pass 
unrecognized,  or  at  all  events  unnamed.  It  is  the  failure 
to  recognize  the  onset  of  melancholia  in  acute  neuras- 
thenics that  results  in  many  cases  of  attempted  suicide, 
for  although  indecision  may  be  present,  impediment  of 
will  is  not  at  all  marked  in  the  early  stages. 

Continuous  undivertible  depression  arising  in  cases  of 
neurasthenia,  depression  unrelieved  by  intervals  of 
relative  comfort  of  mind  due  to   coenesthetic  changes, 


COMBINED  AND  ATYPICAL  PSYCHOSES     193 

unalterable  by  pleasant  environment  in  its  fullest  and 
happiest  sense,  and  unrelieved  by  bed,  indicates  melan- 
cholia. Acute  neurasthenics,  however  miserable,  agi- 
tated and  apprehensive,  escape  spontaneously  from  the 
deeps  for  short  periods.  Waves  of  alternate  wretchedness 
and  comparative  comfort  pass  over  them.  Except  in  rare 
cases  (see  below)  their  apprehension  never  takes  an  ex- 
ternal mental  content ;  it  is  always  a  physical  one,  of  im- 
pending death,  insanity,  or  some  ill-defined  bodily  catas- 
trophe ;  and  it  is  accompanied  by  physical  signs  of  fear, 
e.  g.,  tremors,  sweats,  raised  eyelids,  dilated  pupils,  rest- 
lessness, palpitation.  The  development  in  such  cases  of  a 
quiet  fixed  apprehension  pari  passu  with  the  subsidence 
of  physical  agitation  is  indicative  of  the  onset  of  melan- 
cholia, as  is  also  self-depreciation  in  connection  with  the 
whole  past,  not  merely  specific  incidents. 

The  blood  pressure  being  low  in  acute  neurasthenia 
and  high  in  melancholia,  one  would  expect  to  notice  a 
change  when  the  latter  supervened.  In  reference  to 
psychasthenic  symptoms  it  has  already  been  said  that 
irrepressible  ideas  may  develop  in  cases  of  melancholia 
into  fixed  ideas,  viz.  delusions  (p.  122). 

Cases  are  met  with  however  in  which  such  a  transition 
occurs  unaccompanied  by  deep  continuous  depression  and 
impediment  of  will,  but  in  which  self-depreciation  is 
present.  It  is  sometimes  found  in  these  cases  that  the 
patient  has  always  been  of  psychasthenic  temperament ; 
that  as  the  result  of  some  trauma  (emotional)  he  has 
developed  a  mild  attack  of  melancholia  with  delusions 
of  psychasthenic  origin  ;  and  that  the  state  described 
above  remains  after  partial  recovery  from  the  melan- 
cholia, the  ideas  persisting,  when  once  fixed,  owing  to  the 
incoercibility  of  psychasthenia. 

Patients  presenting  such  a  picture  should,  however, 
be  watched  very  closely  indeed  for  signs  of  an  early 

e.m.d.  13 


194    ATYPICAL  AND  COMBINED  PSYCHOSES 

dementia  praecox.  One  should  also  bear  in  mind  the 
question  of  paranoidal  amentia,  which  does  occasionally 
supervene  upon  psycho-neurasthenia,  the  diathesis  of 
incoercibility,  i.  e.,  psychasthenic  temperament  not  un- 
commonly being  found  to  have  pre-existed  in  such  cases. 
Confusion  and  hallucinations  would  occur  when  paranoidal 
amentia  developed.  Apart  from  combinations  with 
melancholia,  early  dementia  prsecox,  amentia,  etc.,  there 
yet  remains  a  class  of  case  in  which  delusions  develop 
directly  out  of  psychasthenia  and  are  accompanied  by 
obsessive  disorder  of  conduct. 

These  types,  I  think,  justify  the  use  of  the  term  psych- 
asthenic insanity.  It  is  here  suggested  that  the  con- 
stitutional fearfulness  of  psychasthenia  is  incapable  of 
spontaneously  causing  this  psychosis,  but  that  it  may 
supervene  upon  some  special  emotional  trauma  sustained 
by  a  person  of  psychasthenic  temperament. 

Although  the  present  writer  does  not  believe  in  the 
invariably  sexual  theories  on  which  it  is  endeavoured  to 
base  psycho-analysis,  and  is  of  the  opinion  that  it  is 
perfectly  futile  to  psycho-analyze  the  ordinary  melan- 
cholic or  adolescent  dement  (though  tins  is  quite 
commonly  done  through  lack  of  close  clinical  observa- 
tion) 1 — that  it  is  unnecessary  and  unkind  to  psycho- 
analyze neurasthenics,hysterics,  and  simple  psychasthenics, 
that  it  is  impossible  to  subject  an  ament  or  a  paralytic  to 
such  a  process — yet  he  believes  that  cases  of  psychasthenic 
insanity  in  which  no  cause  can  be  found  (i.e.,  the  trauma 
has  been  suppressed  and  forgotten)  ought  to  be  psycho- 
analyzed if  hypnotic  suggestion  and  other  means  fail. 

1 1  have  recently  read  of  a  case  subjected  for  months  to  some 
sort  of  psycho-analysis  and  therapeutic  talk,  which  to  the  author's 
distress  produced  little  or  no  result.  It  is  well  described  and  is 
about  as  typical  a  case  of  longstanding  dementia  preecox  as  one 
could  wish.  A  little  clinical  knowledge  would  have  saved  this 
futile  waste  of  time, 


COMBINED  AND  ATYPICAL  PSYCHOSES     195 

Cases  in  which  the  trauma  is  discoverable  should  have 
the  whole  process  explained  to  them,  and  be  taught  how 
to  tackle  both  it  and  themselves. 


2.  Melancholia  with  Mania  (see  p.  189) 
3.  Melancholia  with  Confusional  Symptoms 

Some  remarks  on  this  subject  have  been  made  on 
page  53. 

Confusional  symptoms  are  met  with  both  in  agitated 
and  stuporose  melancholia.  The  main  practical  point  is 
the  recognition  of  such  cases,  so  that  confusion  with 
totally  distinct  syndromes  may  be  avoided. 

For  example,  a  continually  depressed  and  emaciated 
person  who  lies  about  silent  and  inert  and  has  to  be 
urged  to  carry  out  the  simplest  acts  of  life,  but  who,  in 
spite  of  disorientation  and  hallucinations,  understands 
and  after  an  effort  slowly  obeys  simple  commands, 
should  not  be  mistaken  for  an  alcoholic,  an  adolescent 
dement  or  an  ament.  Similarly,  an  acutely  continuously 
miserable,  restless  and  agitated  woman,  who  hears  the 
voices  of  her  children  calling  to  her,  and  thinks  that  she 
is  doomed  to  eternal  damnation  or  speedy  death  because 
she  has  neglected  them — who  refuses  her  food,  ties  her 
night-dress  round  her  neck,  wails  and  wrings  her  hands, 
but  who  does  nothing  illogical  in  view  of  her  emotional 
and  ideational  state,  and  replies  naturally  when  ques- 
tioned— is  suffering  from  melancholia  with  exhaustion 
symptoms. 

4.  Melancholia  with  Chronic  Alcoholism 

Cases  are  met  with  in  which  apparent  alcoholic  syn- 
dromes are  accompanied  by  an  unusually  constant  and 
continuous  state  of  depression,  together  with  impediment 


196    ATYPICAL  AND  COMBINED  PSYCHOSES 

of  will,  or  in  which,  apparent  melancholies  manifest 
definite  signs  of  chronic  alcoholism.  In  some  of  them  a 
history  of  previous  attacks  of  depression  is  forthcoming, 
or  a  history  that  the  alcoholism  has  resulted  from  a 
generally  gloomy  outlook  upon  fife. 

Typical  cases  show  a  marked  misery  deepening  into 
melancholic  stupor.  In  these  the  main  feature  is  the 
melancholia.  Intervals  of  relative  cheerfulness  showing 
the  semi-humorous  mood ;  hallucinations,  and  other 
alcoholic  features,  indicate  a  superimposed  alcoholism. 
In  other  cases  the  alcoholic  symptoms  are  the  more 
prominent. 

For  example,  there  may  be  dull  apprehensive  depression, 
and  impediment  of  will — showing  itself  in  silence,  sitting 
about  alone,  slow  re-action  to  questions — together  with 
conspicuous  hallucinations  of  hearing,  delusions  of  per- 
secution, good  perception,  complete  accessibility  and 
understanding  of  the  status  quo,  and  physical  signs  of 
alcoholism,  and  the  dull,  coarse,  degraded,  hang-dog 
appearance  of  the  chronic  alcoholic. 

Whether  any  melancholic  element  is  present  in  cases 
of  this  sort  is  mainly  of  academic  interest.  Such  patients 
do  not  recover,  but  as  the  course  proceeds  the  depression 
becomes  less,  and  eventually  the  semi-humorous  mood 
develops.  Probably  those  with  a  previous  history  of 
melancholic  attacks,  or  of  previous  hypo-melancholia,  are 
partly  of  melancholic  origin. 

Another  variety  of  case  is  encountered  in  which  the 
stupor,  though  not  the  depression,  is  much  more  pro- 
nounced. Patients  of  this  class  manifest  much  less 
prominent  hallucinations  and  apprehensive  depression, 
but  on  the  other  hand  more  confusion,  with  disorienta- 
tion and  marked  general  amnesia  more  conspicuous  for 
recent  incidents.  They  stand  about  silent  and  apparently 
indifferent  to  their  surroundings.     When  addressed  they 


COMBINED  AND  ATYPICAL  PSYCHOSES     197 

mutter  or  do  not  reply  at  all.  Yet  they  are  obviously 
miserable. 

Later,  the  amnesia,  confusion,  and  depression  suddenly 
or  gradually  pass  off,  and  in  their  place  appears  a  transit- 
ory phase  of  euphoria,  alertness,  and  exuberance,  fol- 
lowed by  a  return  of  dull  depression  with  hallucinations 
of  hearing  and  delusions  of  persecution,  but  complete 
collectedness.  The  erroneous  ideas  take  the  form  of 
injury  by  unseen  means  or  enemies.  Amnesia  for  the 
confusional  state  remains.  With  all  these  features  there 
is  a  history  of  alcoholism  (as  well  as  signs  of  it),  and  also 
of  previous  attacks  of  depression  alternating  with  cheer- 
fulness (when  everything  seems  bright  and  easy),  both  of 
minor  degree,  hardly  over-stepping  the  bounds  of  the 
normal. 

Psychoses  of  this  sort  are  very  difficult  to  diagnose 
until  they  are  cleared  up  by  their  course. 

The  most  likely  solution  appears  to  be  the  supposition 
of  a  combination  of  maniacal-depressive  insanity  with 
hallucinatory  alcoholic  delusions,  acute  in  the  early  con- 
fused state,  chronic  later.  Possibly  some  other  intoxica- 
tion of  unknown  origin  co-exists  in  the  initial  confusional 
attack. 

5.  Melancholia  and  Hysteria 

Hysterical  depression  and  weeping,  apart  from  melan- 
cholia, may,  if  prolonged,  lead  to  the  suspicion  of  melan- 
cholia. It  is  not  however  characterized  by  steady  misery, 
but  by  sudden  changes,  lightenings,  and  sometimes  occa- 
sional laughter,  followed  by  showers  of  easily  shed  tears. 
There  is  an  exaggerated  emotional  reaction  and  general 
instability  of  mood,  moreover  the  unhappiness  is  not  very 
deep  in  spite  of  its  pronounced  expression.  In  melan- 
cholia such  outward  show  of  unhappiness  would  only 


198    ATYPICAL  AND  COMBINED  PSYCHOSES 

occur  in  pronounced  unmistakable  cases.  Hysterical 
depression  per  se  is  never  accompanied  by  impediment  of 
will. 

True  melancholia  in  hysterical  persons  is  shorter,  more 
demonstrative,  and  less  severe  than  in  uncomplicated 
cases. 

The  development  in  a  case  of  hysteria  of  persistent 
depression  with  impediment  of  will  indicates  the  onset 
of  melancholia,  just  as  it  would  in  a  person  not  of 
hysterical  temperament. 

4.  COMPLICATED  COMBINED  PSYCHOSES 

Three  or  more  mental  syndromes  may  naturally  be 
associated  in  one  individual,  but  the  association  is  not 
very  common.  From  the  brief  account  of  double  syn- 
dromes given  above,  not  by  any  means  exhausting  the 
possibilities  of  such  combinations,  aided  by  a  thorough 
clinical  knowledge  of  well-defined  single  psychoses,  the 
attainment  of  some  idea  of  the  clinical  pictures  produced 
by  complicated  types  will  be  possible.  The  exact  diag- 
nosis, however,  of  some  of  them  will  always  remain  a 
difficult  task,  only  to  be  facilitated  by  careful  study  of 
actual  cases.  The  complex  manifestations  of  them  cannot 
be  predicted  merely  from  a  theoretical  knowledge  of  the 
symptoms  found  in  the  component  psychoses,  combined 
with  an  acquaintance  with  psychology,  for  it  is  found  that 
apparently  incompatible  psychological  disorders  do,  in 
fact,  exist  in  one  case.  Nevertheless  the  combinations 
possible  are  not  susceptible  of  extension  ad  infinitum. 

Careful  record  of  combined  cases  as  they  are  encoun- 
tered should  be  kept  by  all  alienists,  so  that  their  nature 
and  limits,  the  influence  of  one  symptom  upon  another, 
may  eventually  be  determined,  and  not  only  will  precise 
clinical  knowledge  be  enriched  thereby,  but  our  under- 


COMBINED  AND  ATYPICAL  PSYCHOSES     199 

standing  of  the  psychology  of  the  insane  and  sane  mind 
considerably  enlightened. 

Some  conception  of  the  involved  nature  of  the  subject 
will  be  gathered  by  consideration  of  the  possibility  of  a 
combination,  for  example,  of  mania  with  exhaustion 
symptoms,  or  amentia  or  chronic  alcoholic  syndromes, 
occurring  in  an  imbecile  suffering  from  paranoical  tend- 
encies ;  or  a  case  of  periodic  mania  in  an  alcoholic 
manifesting  epileptic  fits  ;  or  a  paranoiac  developing 
neurasthenia  at  the  onset  of  G.P.I. 

At  present  cases  of  this  sort  can,  for  the  most  part, 
only  be  elucidated  by  a  thorough  knowledge  of  the 
patient's  history  and  by  observation  of  the  course  of  the 
disorder. 


ALPHABETICAL    GLOSSARY     OF    TERMS 
EMPLOYED 

1 .  Accessibility  : 

The  state  or  condition  in  virtue  of  which  a  person's  atten- 
tion can  be  claimed  and  his  understanding  activated  by 
external  agents. 

2.  Amimia  : 

Loss  of  facial  expression  due  to  muscular  paresis. 

3.  Amnesia  : 

Loss  of  memory. 

4.  Attention  : 

The  state  of  an  individual  when  placed  in  the  best  atti- 
tude to  receive  sensations  from  an  object  perceived  or 
experienced  by  the  senses. 

(a)  Active      attention      (syn.      Voluntary      attention). 

The  state  when  achieved  by  an  action  of  will. 
(6)  Passive    attention    (syn.    Involuntary,    instinctive 
attention),  the  state  when  brought  about  without 
conscious    volition,   *.  e.   having    the     attention 
claimed  by  an  external  stimulus. 

5.  Atjtocbiticism  : 

The  faculty  of  understanding  one's  own  condition. 

6.  Automatic  Obedience  : 

(a)  Echopraxis. 

Purposeless  repetition  of  the  actions  of  others. 
(6)  Echolalia. 

Purposeless  repetition  of  the  speech  of  others. 
(Both  conditions  mainly  occur  in  dementia  prsecox.) 
201 


202  GLOSSARY 

7.  Catalepsy  : 

(a)  Flexibilitas  cerea. 

A  condition  in  which  a  person's  limbs,  etc.,  remain 
for  considerable  periods  in  any  position  in  which 
they  are  placed  by  another. 

(6)  Automatic  obedience  (vide  supra). 

8.  Cosnesthesis  (see  Euphoria). 

9.  Comprehension  : 

Used  in  this  book  to  indicate  understanding  of  what  is 
said. 

10.  Confusion  of  Speech  : 

Meaningless  unintelligible  talking,  often  with  disintegra- 
tion of  words  (cf.  Incoherence). 

11.  Disorientation  : 

Absence  of  knowledge  of  position  with  regard  to  place  or 
time. 

12.  DrvERTiBrLiTY : 

The  quality  in  virtue  of  which  the  mood,  thoughts,  or 
conduct  can  be  influenced  by  the  suggestion  of  others,  or 
by  external  stimuli. 

13.  Echolalia,  Echopraxis.     See  Automatic  Obedience. 

14.  Equivalents  : 

(Psychical  or  motor,  in  epilepsy.) 

States  occurring  instead  of,  or  in  association  with,  epileptic 
fits.  They  are  sudden,  short,  periodical,  frequent,  cause- 
less, and  similar  in  those  of  the  same  type. 

15.  Euphoria  : 

A  feeling  of  personal  well-being  dependent  upon  the 
pleasantness  of  the  sum  total  of  unrecognised  bodily 
sensations,  *.  e.  of  the  Coenesthesis. 

16.  Hallucination  : 

Imaginary  perception  (vide  infra).     An  hallucination  is  a 
pathological  percept  or  sensation  occurring  without  the 
presence  of  external  stimuli  to  produce  it. 
(a)  Elementary  hallucinations,  e.  g.  flashes  of  light,  ringing 

in  the  ears,  etc. 
(6)  Organized  hallucinations,  e.  g.  imaginary  voices,  figures, 

etc. 
(In  this  book  the  term  hallucination  used  alone  indicates 
organized  hallucination.) 


GLOSSARY  203 

17.  Ideation  : 

The  process  by  which  a  former  percept  (or  percepts), 
rises  into  consciousness.  An  idea  is  a  percept  revived 
in  the  mind  by  association  in  the  absence  of  the  external 
stimuli,  which  gave  rise  to  the  original  percept,  i.  e.  in 
the  absence  of  the  object  prodiicing  the  stimuli  {vide  per- 
ception infra),  e.  g.  in  a  simple  form  ;  one  sees  a  tart  which 
by  association  evokes  the  idea  of  apples. 

Concepts  or  conceptions  are  general  ideas  of  abstract 
nature,  in  fact,  abstractions,  e.  g.  darkness,  light,  good, 
evil. 

18.  Ideational  Inertia  : 

The  persistence  of  an  idea  and  its  application  to  objects 
other  than  that  from  which  the  percept  giving  rise  to 
the  idea  was  derived,  e.  g.  a  patient  is  shown  a  cup  of  tea, 
then  a  coal-scuttle  (which  he  knows  is  a  coal-scuttle)  the 
idea  "  cup  of  tea  "  persisting,  he  says  the  coal-scuttle  is 
for  holding  cups  of  tea  :  a  cupboard,  for  storing  cups  of 
tea,  etc. 

19.  Illusion  : 

Erroneous  perception.  Perception  of  one  object  when 
the  sensations  experienced  arise  from  another. 

20.  IacPERCEPTiON  : 

Absence  of  perception.  Inability  to  combine  sensations 
arising  from  an  object  to  form  a  percept- — a  single  mental 
picture  of  that  object ;  e.  g.  if  a  man  sees,  smells,  and 
handles  an  orange,  but  does  not  know  what  it  is,  in  spite 
of  former  experience  of  oranges,  he  is  suffering  from 
imperception. 

21.  Incoherent  Speech  : 

Speech  composed  of  detached  phrases,  disconnected  or 
unfinished  sentences,  which  is  nevertheless  intelligible 
and  an  expression  of  ideas. 

22.  Katatonia  : 

A  disorder  of  conduct  in  which  actions  result  from  abnormal 
internal  stimuli  and  not  motives.     The  term  is  used  loosely. 


204  GLOSSARY 

As  defined  above,  some  degree  is  always  present  in  De- 
mentia Prsecox.  In  its  usual  sense  it  means  especially, 
minor  motiveless  actions,  such  as  purposeless  movements 
of  limbs,  etc.,  rigid  attitudes  and  absurd  poses.  It  is 
also  used  to  indicate  the  variety  of  dementia  prsecox  in 
which  these  symptoms  and  those  mentioned  below,  (a) 
and  (6)  are  prominent.  Katatonia  includes  the  special 
symptoms  : — 

(a)  Negativism.     A    condition   in    which   any   external 
stimuli  to   action  give  rise  to   internal   stimuli 
producing  action  of  an  opposite  nature. 
(6)  Stereotypism.     Multiple  repetition  of  the  same  move- 
ments or  forms  of  speech  :    in  the  latter  case 
called  verbigeration. 
Katatonia   in   well-marked   forms   is   almost   peculiar   to 
dementia  prsecox. 

23.  Mannebisms — in  Dementia  Prsecox. 

A  minor  indication  of  Katatonia,  *.  e.  purposeless  tricks 
of  manner,  gestures  and  speech,  peculiar  stiff,  affected  or 
pedantic  fashions  of  carrying  out  ordinary  acts. 

24.  Mentation  : 

Used  in  this  book  to  indicate  mental  action  in  general, 

25.  Mtjtactsmtjs  : 

An  example  of  negativism — forced  dumbness. 

26.  Negativism  : 

Vide  Katatonia  supra.  Examples  :  a  patient  asked  to 
show  his  tongue,  clenches  his  teeth.  Requested  to  shake 
hands,  puts  his  behind  him  :  neither  acts  being  the  result 
of  personal  resentment  or  of  any  motive  at  all. 

27.  Neologism  : 

Coining  of  new  words.  This  may  be  to  supply  a  want, 
e.  g.  to  describe  a  mode  of  imaginary  persecution  in  para- 
noidal  cases ;  or  the  neologism  may  have  no  ideational 
content,  as  sometimes  occurs  in  Dementia  Prsecox. 

28.  Obsessions  : 

Imperative  impulses  to  action,  which  meet  with  resistance 
on  the  part  of  their  subject  (see  Psychasthenia). 


GLOSSARY  205 

29.  Orientation  : 

Knowledge  of  one's  position  in  relation  to  time  and  space 
(c/.  disorientation). 

30.  Perception  : 

The  process  by  which  existing  sensations  arising  from  an 
object  present,  are  combined  to  form  a  mental  unity 
peculiar  to  that  object,  e.  g.  an  apple  giving  rise  to  sensa- 
tions, visual,  tactile,  olfactory,  etc.,  enables  one  to  experi- 
ence a  concrete  percept  "  apple,"  which  is  capable  by  a 
process  of  association  of  being  revived  as  the  idea  of  an 
apple  in  its  absence,  e.  g.  by  seeing  a  pie  or  a  fruit  knife 
{vide  Imperception  and  Ideation,  supra). 

By  combining  simple  percepts  and  ideas,  complicated 
percepts  and  general  ideas  are  produced,  e.  g.  one  sees  a 
long  room  full  of  beds,  tidy  and  clean,  with  tables  bearing 
bottles  of  medicine,  and  medical  appliances ;  these  indi- 
vidual percepts  and  the  ideas  to  which  they  give  rise  by 
association  are  combined  and  one  apprehends  that  the 
room  is  a  hospital  ward.  Inability  so  to  combine,  results 
in  disorientation. 

31.  Press  of  Occupation  : 

A  condition  resulting  in   continual  action. 

32.  Pseudo-hallucinations  (Auditory). 

"  Audible  thought."  These  hallucinations  are  peculiar 
to  dementia  prsecox.  The  essential  practical  difference 
between  them  and  true  hallucinations  is  that  their,  subject 
does  not  localize  them  externally  to  himself ;  i.  e.  they 
do  not  sound  the  same  to  him  as  actual  voices.  Varied 
descriptions  are  given  by  a  patient  subject  to  these,  e.  g. 
his  thoughts  are  repeated ;  others  project  their  thoughts 
into  his  head.     But  their  internal  nature  remains  constant. 

33.  Pseud o -reminiscence  : 

Falsification  of  memory.  "  Recollection  "  of  incidents, 
etc.,  that  have  not  occurred. 

34.  Seclusiveness  : 

Desire  for  or  purposeless  impulse  towards  solitude. 


206  GLOSSARY 

35.  Stereotypism,  vide  Katatonia  (supra). 

36.  Syllable  Stumbling  : 

Stuttering  and  elision  and  transposition  of  syllables  in 
G.P.I.  Tests  :  "  Irish  Artillery,"  "  Compulsory  Registra- 
tion." 

37.  Verbigeration  : 

Vide  Katatonia  (supra). 


INDEX 


Abiotrophy,  103 
Abstinence  symptoms,  47 
Accessibility,  201 
Acute  confusional  insanity,  22, 
33 

—  delirium,  22 
Adenoids,  4 
Adolescence,  3,   18,  21 
iEtiology,  1 
Affectation,  21,  54,  67 
Alcoholic  facies,  73,  75 

—  impairment,  74,  112 
- —  mania,  69,  71 

—  pseudo-paresis,  36,  77 
—syndromes,    33,    36,  69,  71, 

74,    83,    85,  112,   171,  188 

Alertness,  24 

Alternating  insanity.  See  Ma- 
nic depressive  insanity 

Altruism,  6,  108,  115,  124,  148, 
177 

Amentia  agitata,  22,  34,  172, 
189 

—  attonita,  53,  89,  123,  124 

—  paranoides,    81,    122,    169, 

184,  194 
Amential  episodes,  31,  37,  46, 

169,  182,  189,  195 
Amimia,  29,  201 
Amnesia,  23,  59,  98,  103,  105, 

106,  107,  112,  152,  201 
Amour  propre,  21 


Anergic  stupor,  122 
Anomaly,  61,  147,  166,  176 
Anxiety  neurosis,  5,  100,  121, 

128,  133,  152,  154,  163 
Apathy,   3,    19,   99,    101,    183. 

See   also   Emotional   dull- 
*       ness 

Apoplectic  dementia,  114 
Apprehension,  23,  33,  49,  58, 

70,  72,  82,  90 
Arterio  sclerotic  dementia,  104 
Artistic  temperament,  3 
Attention,  201 
Attitudes,  88,  184,  186 
Atypical  psychoses,  166 
Autocriticism,  15,  57,  99,  174, 

201 
Auto-intoxication,  22,  33,  38, 

50,   128,   134 
Automatic  obedience,  201 
Automatism,     128,     130,     152, 

164,  165 

Blood  pressure,  193 
Borderline  types,  10,  119-147 
Bromides,  5,  22,  41,   108 

Catalepsy,  202 
Causation,   1 
Cerebral  tumours,  42 
Childishness,   103,  108,  115 
Childhood,  3 

207 


208 


INDEX 


Chronic  alcoholism,  33,  36,  69, 
71,74,83,112,188,190,195 

—  mania,   15,  18 
Circular  stupor,  86 
Classification,  ix 

Clouding  of  consciousness,  23, 

33,  36,  38,  50,  69,  84,  89, 

91,  93 
Coenesthesis,  202 
Collapse,  23,  28 
Combined  psychoses,  45,  166- 

198 
Common  mental  disorders,  12- 

116 
Complexes,  7,  137,  163 
Complicated  psychoses,  198 
Comprehension,  202 
Concepts,  114,  203 
Conflict,  5,  128,  137,  163 
Confusion  of  speech,  202.     See 

Meaningless  speech 
Constitutional  immorality,  147, 

167,  174,  176 
Continuous  warm  bath,  18 
Cretins,  132 
Criminals.     See  Constitutional 

immorality 

Debauchery,  7 
Degeneration,  2,  8 
Delirious  mania,  22 
Delirium  of  collapse,  22 
Delirium  tremens,  33 
Delusions,   15,  20,  29,  33,   50, 

54,    61,    70,    74,    88,    101, 

112,  184 
Dementia  paralytica,  98.      See 

also  G.P.I. 

—  paranoides,  64,  66,  172 

—  praecox,   6,   18,  24,   54,   66, 

87,  90, 101, 170, 174, 178,194 
— senilis,  102 


Diathesis.     See  Temperament 
Dipsomania,  33,  129 
Disorientation,  202 
Divertibility,  202 
Drug  insanities,  47 

Eccentrics,  123 
Echolalia,  201 
Echopraxis,  201 
Education,  2,  4,  115 
Egotism,  3,  6,  10,  58,  60,  104, 

124 
Emotional    dullness,    20,     54, 

77,   89,   90,   99.     See  also 

Apathy 
Endogenous  intoxication,  22 
Epilepsy,  38,  59,  91,  107,  174, 

187 
Equivalents  (epileptic),  40,  59> 

91,  109,  129,  175,  202 
Eroticism,  186 
Euphoria,   31,   37,   56,  68,  76, 

99,  202 
Exhaustion,    18,    22,    50,    122, 

190,  195.     See  also  Amen- 

tial  episodes 
Exogenous  intoxications,  25,  47 
Exophthalmic  goitre,  133 
Expansive    delusions,    29,    37, 

76,  191 

Falsification  of  memory.  See 
Pseudo  -  Reminiscence 

Fits,  33,  40,  45,  59,  99,  107, 
129,  140,  146,  152,  155, 
159,  161,  162,  164,  169, 
176,  187 

Flight  of  ideas,  14,  20,  23,  183 

Focal  symptoms,  103,  105,  114 

Galloping  G.P.I.,  28 


INDEX 


209 


General  paralysis  of  insane,  28, 
56,76,93,98,  173,174,  191 
Glossary,  201 

Grandiose  delusions,  28,  56,  69 
Gumniata  (cerebral),  105 

Hallucinations,  14,  20,  33,  54, 
62,  67,  72,  82,  102,  202 

Hallucinatory  delusions,  69,  71, 
191 

Hebephrenia,  91 

Heredity,  2 

Homosexuality,  61 

Hyoscine  hydrobromide,  17, 
36,  46,  109 

Hypnotism,  141,   149 

Hypochondria,  49,  58,  63,  78, 

172,  173 
Hypomania,   14,  116,  119,  171 
Hypo-melancholia,  120,  196 
Hysteria,   120,   121,   130,   135- 

147,    152,    162,    163,    171, 

173,  185,   191,  197 

Ideation,  203 

Ideational  inertia,  103,  104,  203 

Idiocy,   114 

Idiopathic  epilepsy,  164 

Illusions,  14,  33,  41,  203 

Imbecility,    6,    114,    167,    168, 

174,  177 
Immobility,  86 
Impediment  of  will,  50,  193 
Imperception,  203 
Incoherence,  203 
Individual,  1,  135 
Insomnia.     See  Sedatives 
Instability,  2,  3,  8 
Instincts,  61,  126,  135 
Irrepressible    ideas,    121,    125, 

'    178 
—  impulses.     See  last 

E.M.D. 


Jealousy  (delusions  of),  68,  74 

Katatonia,  19,  30,  54,  87,  102, 

170,   183,  203 
Katatonic  excitement,  18 
—  stupor,  87 
Korsakoff's  syndrome,  83 

Liability  to  insanity,  4 
Lucid    intervals.     See    Remis- 


Mania,  13,  46,  189,  195 

Maniacal  G.P.I. ,  28 

—  stupor,  95,  122 

Manic  depressive  insanity,  13, 

49,   58,   86,   95,  116,   119, 

122,   170,  189,  195 
Mannerisms,  204 
Marriage,  6,  7 
Masked  epilepsy,  33,  128 
Masturbation,  5 
Mattoids,  62,  123,  177 
Meaningless  speech,  19,  20,  67, 

202 
Megalomania.     See  Expansive 

delusions 
Melancholia,  49,  58,  120,  189, 

192,  195 
Menopause,  63 

Mental   fatigue,  100,  105,  124 
Mentation,  204 
Monomaniacs,  123 
Moroseness,  3,  72 
Morphinism,  47 
Motiveless  conduct.      See  Pur- 
poseless acts 
Mutacismus,  87,  204 
Mutism,  86 
Myxcedema,  132 

Negativism.     See  Katatonia 
15 


210 


INDEX 


Neologism,  21,  54,  204 
Neurasthenia,   5,   7,    100,   120, 

121,    124,    126,    128,    133, 

154,  173,  178,  192 
Neurons,  145 
Neurosis,  128 
Neurotics,  3 
Night  terrors,  3 

Obsessions,  125,  180,  204 

Obstinacy,  3,  51 

Organic  brain  disease,  42,  105, 

114,  169 
Orientation,  205 

Paranoia,  61,   171,  176 
Paranoiacal  temperament,   15, 

61,  79,  123,  172,  173 
Pedantry,  21,  54,  67,  181 
Perception,  205 
Periodic  mania,  15 
Persecutory  hypochondria,  63 
Persuasion,  16,  21,  42,  70 
Perversity,  3,  22 
Phobias,  125 
Physical    signs  of    alcoholism, 

34,  37,   74 
—  —   G.P.I.,    29,  37,  99 

of  neurasthenia,  181, 193 

Polyneuritic  psychosis,  83 
Preconception,  61,  123,  173 
Press  of  occupation,  14,  205 
Propagandists,  62,  123 
Pseudo -Hallucinations,  67,  102, 

173,  179,  205 
Pseudo -Reminiscence,    40,    61, 

73,  84,  205 
Psychasthenia,   121,   124,   133, 

154,  163,  178,   192 
Psychasthenic  insanity,  194 
Psychical  treatment,  8 


Psycho-analysis,    9,    127,    141, 

194 
Puberty,  5,  58 
Purposeless   acts,    19,   20,    23, 

54,  67,  102,  126 

Raptus  melancholicus,  50,  53 

Recluses,   123 

Recurrence,  13,  28,  34,  49,  86, 

96 
Religion,  5,  7,  60,  123,  150 
Remissions,  23,  24,  28,  34,  45, 

65,  88,  95,   106,  169 
Reticence,   10,  182 

School,  4 

Seclusiveness,  5,  54,  180,  206 

Sedatives,   17,  26,  36,  42,   52, 

104,  109 
Self-depreciation,  51 
Self-puzzled  state,  59,  90 
Semi-humorous  mood,  34 
Senile  delusions,  68 

—  dementia,  102 

—  depression,  58 

—  excitement,  46 

Sexual  instinct,  5,  8,  61,  140, 

142 
Shell  shock,  143-146,  157 
Similar  heredity,  2 
Simple     stupor     in     dementia 

prsecox,  90 
Skin  toilette,  27,  32 
Smiling,  21,  54,  88,  179,  183 
Somatic  episodes  (in  hysteria), 

136 
Stereotypism,     19,     204.     See 

Katatonia 
Stigmata  of  degeneration,  3 
Stumbling  slow  mentation,  41, 

60,  91,  107 
Stupefaction,  33 


INDEX  211 

Stupor,  50,  86,  90,  91,  93,  95,  Thyroid  psychoses,   132 

168,  184  Treatment,   1 

Subconscious  ego,  61,  135  Tube  feeding,  26,  47,  87,   88 

Sublimation,  5,   137  Typhoid  state,  23 
Suggestibility,   182 

Suicide,  35,  40,  50,  52,  55,  66,  Uncontrollable  temper,   3,   129 

67,  70,  87,  88,  101,  121  Unhappiness,  160    * 

Sulphonal,  17,  18,  22  Unseen  agencies,  64 

Suppression,    5,    8,     128,    137,  Unstable  stockgj  2 

163'   164  Uraemia,  25,  33 
Syllable  stumbling,  206 

Syphilitic  dementia,  105  .     . 

-  pseudo-paresis,  106  Valetudinarianism,  3 

Systematised  delusions,  61,  68,  Vengefulness,  3 

79    171    172  Verbigeration,  20,  54,  183,  206 

Vice,  3 

Temperament,    4,    13,   49,    61,  Visual  hallucinations,  33,  37 

63,  102,  108,  119,  120,  123, 

125,    129,    133,    135,    158,  Wassermann  test,  37 

164,   185,  188  Wound-up  temper,  60,  108,  129 


Butler  &  Tanner,  Frome  and  London. 


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